Long-term pulmonary complications of chemical warfare agent exposure in Iraqi Kurdish civilians

From Holocaust to Anfal: The impact of genocide and cross-generational trauma on the mental health of Kurds

Genocide attempts are among the most severe traumatic events that are transmitted across generations. However, it may also prove the strength and survivability as well as the vulnerability of the targeted group. Anfal and chemical attacks on Halabja on Iraqi Kurds that targeted their annihilation had a devastating impact. Many survivors and their generations are still dealing with their effects on psychological disorders such as posttraumatic stress disorder (PTSD) and depression. To address the psychological effects of these tragic events on survivors and their generations and propose the actions to be taken, this article explores the psychological trauma and problems caused by attempted genocide and chemical attacks in the case of Anfal campaign. These effects require more research to fully understand the long-term effects of these tragedies, as well as support and provision of comprehensive psychological and mental health interventions to their survivors and generations.

Toxic chemical exposures among civilians in armed conflicts: the need for research equity, justice, and accountability

OBJECTIVE

Armed conflicts result in the release of toxic chemicals into the surrounding environment and civilians are commonly exposed to these toxicants. This paper reviews the evidence on civilian exposure to toxic chemicals, including but not limited to inhaled toxic substances, in post-World War II armed conflicts, and proposes a framework for the implementation of long-term surveillance programs for these populations.

MATERIALS AND METHODS

Four databases of peer-reviewed health articles were searched for all English-language articles with a primary focus on toxic chemical exposures among civilians in armed conflicts since World War II. The review was supplemented substantially by the gray literature.

RESULTS

In the 66 articles that met the inclusion criteria, the authors categorized the chemical toxicants to which civilians have been exposed in modern armed conflicts as ubiquitous (e.g. smoke, dust, and munitions components present in all conflicts) or particular agents (e.g. specific chemical agents used in a few conflicts). While most studies focused on particular agents, the vast majority of civilians are in fact exposed to ubiquitous agents both in the acute conflict phase and through persistent environmental exposures after the cessation of hostilities.

DISCUSSION/CONCLUSION

There is a dearth of research concerning civilian exposures to toxic chemicals during armed conflicts. In line with principles of equity, justice, and accountability, robust research and surveillance programs are urgently needed to document exposures and provide ongoing assessments and any necessary treatment for these long-ignored populations, most of whom live in the Global South.

Respiratory function after 30+ years following sulfur mustard exposure in survivors in Sweden

Background

Sulfur mustard (SM) exposure causes acute and chronic respiratory diseases. The extent of small airway dysfunction (SAD) in individuals exposed to SM is unclear. This study evaluated and compared SAD in SM-exposed and SM-unexposed participants using noninvasive lung function tests assessing small airway function.

Methods

This retrospective cohort study involved SM-exposed (n = 15, mean age: 53 ± 8 years) and SM-unexposed (n = 15, mean age: 53 ± 7 years) Kurdish-Swedish individuals in Sweden. Small airway resistance and reactance were assessed using impulse oscillometry (IOS). Nitrogen (N2) multiple breath washout (MBW) was employed to assess lung ventilation heterogeneity. The gas-exchanging capacity of the lungs was assessed using the diffusing capacity of the lungs for the carbon monoxide (DLCO) test. Lung function outcomes were reported as absolute values and z-scores. Group comparisons were performed using the Mann-Whitney U test.

Results

No statistically significant differences in age, height, or body mass index were observed between the two groups. IOS showed significantly increased small airway resistance, while N2MBW exhibited significantly increased global and acinar ventilation heterogeneity in SM-exposed individuals compared to that in unexposed individuals. SAD was identified in 14 of 15 SM-exposed individuals, defined as at least one abnormal IOS difference between resistance at 5 and 20 Hz (R5-R20) and/or area of reactance (AX) or N2MBW lung's acinar zone (Sacin), and DLCO adjusted to the alveolar volume (DLCO/VA) outcome. Of these 14 individuals, only 5 demonstrated concordant findings across the IOS and N2MBW tests.

Conclusion

Exposure to SM was positively associated with long-term impairment of respiratory tract function in the small airways in the majority of the previously SM-exposed individuals in the present study. Furthermore, both IOS and N2MBW should be employed to detect SAD in SM-exposed survivors as they provide complementary information. Identifying and characterizing the remaining pathology of the small airways in survivors of SM exposure is a first step toward improved treatment and follow-up.

Long-term health complications of chemical weapon exposure: a study on Halabja chemical attack survivors (Iraqi Kurds)

OBJECTIVE

In 1988, the Iraqi government used a range of chemical weapons (CWs) against the Iraqi Kurds of Halabja. Here, we aim to investigate the long-term health consequences in exposed survivors as they are not sufficiently studied.

MATERIALS AND METHODS

This was a retrospective study conducted from November 2019 to May 2020 assessing the health status of all exposed Halabja chemical attack survivors compared to non-exposed people from the same area.

RESULTS AND DISCUSSION

Two hundred thirty survivors and 240 non-exposed participants were enrolled in this study, with control participants matched to age, gender, and occupation. Among the survivors, females were more prevalent. The respiratory system was the most common single exposure route (83, 36.1%), with 138 (60%) of the survivors being exposed by multiple routes. The vast majority (88.7%) of survivors had activities of daily living (ADL) impairment. There was female predominance in mild and moderate cases, with more males in severe cases (p < 0.01). Respiratory and cardiac diseases were significantly more common in the survivors compared to the controls (p < 0.001). Survivors with multiple CW exposure routes had significantly higher rates of ADL impairment (p < 0.001) and cardiac disease, respiratory diseases, and miscarriage (p < 0.01), than those with a single exposure route.

CONCLUSION

In this study comparing CW survivors with a local control population, a single, high-dose exposure to CWs was associated with significant increases in chronic respiratory and cardiac conditions, in addition to high rates of ADL impairment. Similar studies are needed in other, more recent CW survivor cohorts.

Gendered lived experiences of marriage and family following exposure to chemical warfare agents: content analysis of qualitative interviews with survivors in Halabja, Kurdistan-Iraq

OBJECTIVE

To study gendered experiences of the long-term effects of a chemical warfare agent (CWA; sulfur mustard).

DESIGN

Qualitative face-to-face semi-structured in-depth interview study using content analysis approach with thematic analysis and anthropological inquiries.

SETTING

The city of Halabja in the Kurdistan Region of Iraq.

PARTICIPANTS

Survivors of CWA (n=16, female:male 10:6, mean age 45.5 years (range 34 to 67)) with lung damage diagnosis and with a range of sociodemographic variables.

RESULTS

Latent content was expressed as: To get or not to get married? Two categories-social abandonment and uncertain marriage-emerged as expressions of the manifest content. The majority of the participants showed uncertainty as a central concern that affects all decision-making in their private and social life. Uncertainty over marriage and family were huge, corresponding to their fear of giving birth to children with congenital birth defects. Exposure to CWAs was conceptualised in terms of stigmatised illnesses, and consequently resulted in loneliness and social isolation, leading to negative impacts on other aspects of professional and social life. The results demonstrated a gendered pattern: CWA-exposed women were more affected psychosocially than CWA-exposed men. More CWA-exposed women were unemployed, divorced or single, or lived under vulnerable circumstances compared with men.

CONCLUSION

Survivors of CWA exposure have developed a sense of gendered uncertainty around getting married and building a family. Sulfur mustard-exposed women, in particular, long to be desired in the community as they face social exclusion. Survivors should be provided evidence-based consultancy to optimise their decision-making around marriage and other social and family challenges.

Organophosphorus nerve agent poisoning: managing the poisoned patient

Organophosphorus (OP) nerve agent poisoning made the headlines in 2018 with the nerve agent 'Novichok' poisonings in Salisbury, England. This event highlighted a gap in the knowledge of most clinicians in the UK. In response, this special article aims to enlighten and signpost anaesthetists and intensivists towards the general management of OP nerve agent poisoned patients. Drawing on a broad range of sources, we will discuss what OP nerve agents are, how they work, and how to recognise and treat OP nerve agent poisoning. OP nerve agents primarily act by inhibiting the enzyme acetylcholinesterase, causing an acute cholinergic crisis; death usually occurs through respiratory failure. The antimuscarinic agent atropine, oximes (to reactivate acetylcholinesterase), neuroprotective drugs, and critical care remain the mainstays of treatment. The risk to medical staff from OP poisoned patients appears low, especially if there is a thorough decontamination of the poisoned patient and staff wear appropriate personal protective equipment. The events in Salisbury in the past year were shocking, and the staff at Salisbury District General Hospital performed admirably in treating those affected by Novichok nerve agent poisoning. We eagerly anticipate their future clinical publications so that the medical community might learn from their valuable experiences.

Health perspectives among Halabja's civilian survivors of sulfur mustard exposure with respiratory symptoms-A qualitative study

Background

In 1988, Halabja came under heavy chemical warfare attack using chemicals such as sulfur mustard (SM). Thousands of survivors of SM exposure in the city today live with multiple health complaints, such as severe, long-lasting respiratory symptoms; but their perceptions of health have never been adequately researched. We aimed to explore current major health concern topics in civilian survivors with long-term respiratory symptoms.

Method

Sixteen subjects (f:m10:6, mean age 45.5 years (range 34–67)) were interviewed. Study participants were recruited in 2016 via a purposive sampling strategy among civilian survivors of chemical warfare in the city of Halabja in Kurdistan-Iraq. A qualitative research design was applied including semi-structured, face-to-face interviews. Data was analyzed using systematic text condensation.

Results

The analysis yielded fourteen themes related to: (1) General health: all participants described a deterioration in physical and psychological health, following the SM exposure, foremost involving respiratory symptoms, fatigue, sleeping disorders, ocular problems, depressive symptoms, and anxiety; (2) Quality of life: most notably, they reported a limited family life, limited social relations, lack of work ability, and concern about their financial situation. Moreover, many lived in constant fear of a renewed attack; (3) access to health care services: all participants reported that they had no, or only poor, access to health care services and limited access to specialist care, and all reported lack of financial resources to obtain treatment.

Conclusions

The post-exposure somatic and psychosocial effects such as respiratory symptoms of CWA are plausible contributor to poor general health and quality of life among survivors. We conclude that multidisciplinary interventions are needed to tackle the biopsychosocial complications in survivors of SM exposure to minimize further health damage in the future, as well as to promote their health-related quality of life.

An Official American Thoracic Society Workshop Report: Chemical Inhalational Disasters. Biology of Lung Injury, Development of Novel Therapeutics, and Medical Preparedness

This report is based on the proceedings from the Inhalational Lung Injury Workshop jointly sponsored by the American Thoracic Society (ATS) and the National Institutes of Health (NIH) Countermeasures Against Chemical Threats (CounterACT) program on May 21, 2013, in Philadelphia, Pennsylvania. The CounterACT program facilitates research leading to the development of new and improved medical countermeasures for chemical threat agents. The workshop was initiated by the Terrorism and Inhalational Disasters Section of the Environmental, Occupational, and Population Health Assembly of the ATS. Participants included both domestic and international experts in the field, as well as representatives from U.S. governmental funding agencies. The meeting objectives were to (1) provide a forum to review the evidence supporting current standard medical therapies, (2) present updates on our understanding of the epidemiology and underlying pathophysiology of inhalational lung injuries, (3) discuss innovative investigative approaches to further delineating mechanisms of lung injury and identifying new specific therapeutic targets, (4) present promising novel medical countermeasures, (5) facilitate collaborative research efforts, and (6) identify challenges and future directions in the ongoing development, manufacture, and distribution of effective and specific medical countermeasures. Specific inhalational toxins discussed included irritants/pulmonary toxicants (chlorine gas, bromine, and phosgene), vesicants (sulfur mustard), chemical asphyxiants (cyanide), particulates (World Trade Center dust), and respirable nerve agents.

Long-term pulmonary complications of chemical weapons exposure in former poison gas factory workers

CONTEXT

Sulfur mustard (SM) and lewisite are vesicant chemical warfare agents that can cause skin blistering and chronic lung complications. During 1929-1945, a Japanese factory produced poisonous gases, which included SM, lewisite and other chemical weapons. The aim of this study was to investigate the chest computed tomography (CT) findings among long-term survivors who worked at this factory.

METHODS

During 2009-2012, we evaluated chest CT findings from 346 long-term survivors who worked at the poison gas factory. Skin lesions were used as an indicator of significant exposure to vesicant agents.

RESULTS

Among the 346 individuals, 53 (15%) individuals experienced skin lesions while working at the factory, and chest CT revealed abnormal findings in 179 individuals (52%). Emphysema was the most common CT finding and was observed in 75 individuals (22%), while honeycombing was observed in 8 individuals (2%). Emphysema and honeycombing were more prevalent among individuals with skin lesions, compared to individuals without skin lesions. Multivariate analyses revealed significant associations between the presence of emphysema and skin lesions (p = 0.008). Among individuals who never smoked, individuals with skin lesions (n = 26) exhibited a significantly higher rate of emphysema, compared to individuals without skin lesions (n = 200) (35% versus 7%, respectively; p < 0.001).

CONCLUSION

Among the long-term survivors who worked at the poison gas factory, a history of skin lesions was associated with the presence of emphysema, even among never smokers, which suggests that emphysema might be a long-term complication of exposure to chemical warfare agents.

Characterization of Distinct Macrophage Subpopulations during Nitrogen Mustard-Induced Lung Injury and Fibrosis

Nitrogen mustard (NM) is an alkylating agent known to cause extensive pulmonary injury progressing to fibrosis. This is accompanied by a persistent macrophage inflammatory response. In these studies, we characterized the phenotype of macrophages accumulating in the lung over time following NM exposure. Treatment of rats with NM (0.125 mg/kg, intratracheally) resulted in an increase in CD11b(+) macrophages in histologic sections. These cells consisted of inducible nitric oxide synthase(+) (iNOS) proinflammatory M1 macrophages, and CD68(+), CD163(+), CD206(+), YM-1(+), and arginase-II(+)antiinflammatory M2 macrophages. Although M1 macrophages were prominent 1-3 days after NM, M2 macrophages were most notable at 28 days. At this time, they were enlarged and vacuolated, consistent with a profibrotic phenotype. Flow cytometric analysis of isolated lung macrophages identified three phenotypically distinct subpopulations: mature CD11b(-), CD43(-), and CD68(+) resident macrophages, which decreased in numbers after NM; and two infiltrating (CD11b(+)) macrophage subsets: immature CD43(+) M1 macrophages and mature CD43(-) M2 macrophages, which increased sequentially. Time-related increases in M1 (iNOS, IL-12α, COX-2, TNF-α, matrix metalloproteinase-9, matrix metalloproteinase-10) and M2 (IL-10, pentraxin-2, connective tissue growth factor, ApoE) genes, as well as chemokines/chemokine receptors associated with trafficking of M1 (CCR2, CCR5, CCL2, CCL5) and M2 (CX3CR1, fractalkine) macrophages to sites of injury, were also noted in macrophages isolated from the lung after NM. The appearance of M1 and M2 macrophages in the lung correlated with NM-induced acute injury and the development of fibrosis, suggesting a potential role of these macrophage subpopulations in the pathogenic response to NM.

Respiratory complications of organophosphorus nerve agent and insecticide poisoning. Implications for respiratory and critical care

Organophosphorus (OP) compound poisoning is a major global public health problem. Acute OP insecticide self-poisoning kills over 200,000 people every year, the majority from self-harm in rural Asia. Highly toxic OP nerve agents (e.g., sarin) are a significant current terrorist threat, as shown by attacks in Damascus during 2013. These anticholinesterase compounds are classically considered to cause an acute cholinergic syndrome with decreased consciousness, respiratory failure, and, in the case of insecticides, a delayed intermediate syndrome that requires prolonged ventilation. Acute respiratory failure, by central and peripheral mechanisms, is the primary cause of death in most cases. However, preclinical and clinical research over the last two decades has indicated a more complex picture of respiratory complications after OP insecticide poisoning, including onset of delayed neuromuscular junction dysfunction during the cholinergic syndrome, aspiration causing pneumonia and acute respiratory distress syndrome, and the involvement of solvents in OP toxicity. The treatment of OP poisoning has not changed over the last 50 years. However, a better understanding of the multiple respiratory complications of OP poisoning offers additional therapeutic opportunities.

A clinicopathological approach to sulfur mustard-induced organ complications: a major review

CONTEXT

Sulfur mustard (SM), with an old manufacturing history still remains as potential threat due to easy production and extensive effects.

OBJECTIVES

Increasing studies on SM indicates the interest of researchers to this subject. Almost all human body organs are at risk for complications of SM. This study offers organ-by-organ information on the effects of SM in animals and humans.

METHODS

The data sources were literature reviews since 1919 as well as our studies during the Iraq-Iran war. The search items were SM and its all other nomenclatures in relation to, in vivo, in vitro, humans, animals, eye, ocular, ophthalmic, lungs, pulmonary, skin, cutaneous, organs and systemic. Amongst more than 1890 SM-related articles, 257 more relevant clinicopathologic papers were selected for this review.

RESULTS

SM induces a vast range of damages in nearly all organs. Acute SM intoxication warrants immediate approach. Among chronic lesions, delayed keratitis and blindness, bronchiolitis obliterans and respiratory distress, skin pruritus, dryness and cancers are the most commonly observed clinical sequelae.

CONCLUSION

Ocular involvements in a number of patients progress toward a severe, rapid onset form of keratitis. Progressive deterioration of respiratory tract leads to "mustard lung". Skin problems continue as chronic frustrating pruritus on old scars with susceptibility to skin cancers. Due to the multiple acute and chronic morbidities created by SM exposure, uses of multiple drugs by several routes of administrations are warranted.

Birth defects in Iraq and the plausibility of environmental exposure: A review

An increased prevalence of birth defects was allegedly reported in Iraq in the post 1991 Gulf War period, which was largely attributed to exposure to depleted uranium used in the war. This has encouraged further research on this particular topic. This paper reviews the published literature and provided evidence concerning birth defects in Iraq to elucidate possible environmental exposure. In addition to published research, this review used some direct observation of birth defects data from Al-Ramadi Maternity and Paediatric Hospital in Al-Anbar Governorate in Iraq from1st July 2000 through 30th June 2002. In addition to depleted uranium other war-related environmental factors have been studied and linked directly or indirectly with the increasing prevalence of birth defects. However, the reviewed studies and the available research evidence do not provide a clear increase in birth defects and a clear indication of a possible environmental exposure including depleted uranium although the country has been facing several environmental challenges since 1980.

Inhalation of sulfur mustard causes long-term T cell-dependent inflammation: possible role of Th17 cells in chronic lung pathology

Sulfur mustard (SM) is a highly toxic chemical warfare agent that remains a threat to human health. The immediate symptoms of pulmonary distress may develop into chronic lung injury characterized by progressive lung fibrosis, the major cause of morbidity among the surviving SM victims. Although SM has been intensely investigated, little is known about the mechanism(s) by which SM induces chronic lung pathology. Increasing evidence suggests that IL-17(+) cells are critical in fibrosis, including lung fibrotic diseases. In this study we exposed F344 rats and cynomolgus monkeys to SM via inhalation and determined the molecular and cellular milieu in their lungs at various times after SM exposure. In rats, SM induced a burst of pro-inflammatory cytokines/chemokines within 72 h, including IL-1β, TNF-α, IL-2, IL-6, CCL2, CCL3, CCL11, and CXCL1 that was associated with neutrophilic infiltration into the lung. At 2 wks and beyond (chronic phase), lymphocytic infiltration and continued elevated expression of cytokines/chemokines were sustained. TGF-β, which was undetectable in the acute phase, was strongly upregulated in the chronic phase; these conditions persisted until the animals were sacrificed. The chronic phase was also associated with myofibroblast proliferation, collagen deposition, and presence of IL-17(+) cells. At ≥30 days, SM inhalation promoted the accumulation of IL-17(+) cells in the inflamed areas of monkey lungs. Thus, SM inhalation causes acute and chronic inflammatory responses; the latter is characterized by the presence of TGF-β, fibrosis, and IL-17(+) cells in the lung. IL-17(+) cells likely play an important role in the pathogenesis of SM-induced lung injury.

Role of TNFR1 in lung injury and altered lung function induced by the model sulfur mustard vesicant, 2-chloroethyl ethyl sulfide

Lung toxicity induced by sulfur mustard is associated with inflammation and oxidative stress. To elucidate mechanisms mediating pulmonary damage, we used 2-chloroethyl ethyl sulfide (CEES), a model sulfur mustard vesicant. Male mice (B6129) were treated intratracheally with CEES (3 or 6 mg/kg) or control. Animals were sacrificed 3, 7 or 14 days later and bronchoalveolar lavage (BAL) fluid and lung tissue collected. Treatment of mice with CEES resulted in an increase in BAL protein, an indication of alveolar epithelial damage, within 3 days. Expression of Ym1, an oxidative stress marker also increased in the lung, along with inducible nitric oxide synthase, and at 14 days, cyclooxygenase-2 and monocyte chemotactic protein-1, inflammatory proteins implicated in tissue injury. These responses were attenuated in mice lacking the p55 receptor for TNFα (TNFR1-/-), demonstrating that signaling via TNFR1 is key to CEES-induced injury, oxidative stress, and inflammation. CEES-induced upregulation of CuZn-superoxide dismutase (SOD) and MnSOD was delayed or absent in TNFR1-/- mice, relative to WT mice, suggesting that TNFα mediates early antioxidant responses to lung toxicants. Treatment of WT mice with CEES also resulted in functional alterations in the lung including decreases in compliance and increases in elastance. Additionally, methacholine-induced alterations in total lung resistance and central airway resistance were dampened by CEES. Loss of TNFR1 resulted in blunted functional responses to CEES. These effects were most notable in the airways. These data suggest that targeting TNFα signaling may be useful in mitigating lung injury, inflammation and functional alterations induced by vesicants.