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Chapter 35: Medical Challenges in Chemical and Biological Defense for the 21st CenturyThe future requires that we carefully and continually assess the evolving threat from chemical and biological weapons. This can be predicted with certainty: the threat will change with time. As stronger countermeasures are developed by the United States and its allies, the employment of certain agents may become less appealing to adversaries on the battlefield. From that standpoint, medical countermeasures may be an effective deterrent. Biotechnology itself may be the threat of the future, and not specific agents, as adversaries may attempt to evade effective preventive measures with bioengineering. The employment of multiple chemical and biological agents is a very likely scenario of the future, thereby challenging the medical community to be much more proactive in its development of appropriate countermeasures. The missions of the United States military are changing, and deployments will require a capability to address potential chemical and biological incidents on the domestic and international fronts. Military medical personnel must, therefore, be continually prepared to deal with such contingencies as we become an even more important asset to this nation's defense and healthcare structures.United States. Department of the Army. Office of the Surgeon GeneralJohnson-Winegar, Anna; Takafuji, Ernest T.; Zajtchuk, Russ1997
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Chapter 2: History of Chemical and Biological Warfare: An American Perspective"Webster's Ninth New Collegiate Dictionary" defines the term "chemical warfare," first used in 1917, as "tactical warfare using incendiary mixtures, smokes, or irritant, burning, poisonous, or asphyxiating gases." A working definition of a chemical agent is "a chemical which is intended for use in military operations to kill, seriously injure, or incapacitate man because of its physiological effects. Excluded from consideration are riot control agents, chemical herbicides and smoke and flame materials." Chemical agents were usually divided into five categories: nerve agents, vesicants, choking agents, blood agents, and incapacitates. This chapter focuses primarily on the development of chemical and biological weapons and countermeasures to them, thus setting the stage for Chapter 3, Historical Aspects of Medical Defense Against Chemical Warfare, which concentrates on medical aspects of chemical warfare. To avoid excessive duplication of material, protective equipment of the modern era is illustrated in Chapter 16, Chemical Defense Equipment.United States. Department of the Army. Office of the Surgeon GeneralSmart, Jeffrey K.1997
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Chapter 5: Nerve AgentsNerve agents are extremely toxic chemicals that were first developed in secrecy before and during World War II primarily for military use. Related substances are used in medicine, in pharmacology, and for other purposes, such as insecticides, but they lack the potency of the military agents. Much of the basic knowledge about the clinical effects of nerve agents comes from research performed in the decades immediately following World War II. The military stockpiles of several major powers are known to include nerve agents, and the armamentaria of other countries are thought to contain them as well (see Chapter 4, The Chemical Warfare Threat and the Military Healthcare Provider). Because of the possibility of nerve agent use in future conflicts, military medical personnel should have some knowledge of these agents, their effects, and the proper therapy for treating casualties. Therapy is based on the administration of atropine, which interferes with receptor binding of acetylcholine at muscarinic but not nicotinic receptors, and the oxime 2-PAM Cl, which breaks the agent-enzyme bond formed by most agents. Assisted ventilation and other supportive measures are also required in severe poisoning.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.1997
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Chapter 3: Historical Aspects of Medical Defense Against Chemical WarfareIn discussing the history of the use of any new weapon and the medical response to it, one must also describe the context of the weapon: its scientific, social, and political aspects. For chemical warfare, there is the particular idea that chemical weapons are inhumane and immoral. Medical people, who treat the wounded, may well believe that all weapons are inhumane. Nevertheless, even the terms are relative--consider Pope Innocent II, who, in 1139, forbade the use of the relatively new crossbow as "Hateful to God and unfit for Christian Use." His prohibition was cheerfully ignored; the crossbow was used for over 300 years. In this essay, the author will return to the issue of the moral use of the chemical weapon, but he will begin with the early history of chemical warfare itself. The chemical weapon has a long and ancient history, especially in its presentation as flame and smoke. Modern chemistry made possible the use of chemical agents in a logistically and tactically feasible way in World War I. Most of what was known--and is still understood by the public--is based on the gas warfare of 1915-1918. Since then, "poison gas" has usually aroused public repugnance at its use as a weapon. Modest use in the 1930s against tribes and its lack of employment in World War II suggested that "gas warfare" had ended. The discovery of the German nerve gases after World War II, the Cold War, and the utility of tear gas in Vietnam maintained a military interest in the chemical weapon. The use of gas by Iraq against Iranian troops and the threat of Iraqi use in the Persian Gulf War clearly document that chemical warfare remains possible.United States. Department of the Army. Office of the Surgeon GeneralJoy, Robert J. T.1997
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Chapter 8: Long-Term Health Effects of Nerve Agents and MustardAlthough the acute effects of the nerve agents and of mustard agent are well known, the longterm effects after a single exposure or multiple exposures are less well recognized. The nerve agents are the subject of Chapter 5, Nerve Agents, and mustard is a subject of Chapter 7, Vesicants, but this chapter focuses on the long-term effects. Available information implicates the nerve agents and mustard as the cause or probable cause of several long-term health effects. Polyneuropathy, the major neuromuscular manifestation seen after exposure to organophosphate pesticides, has not been reported in humans after exposure to nerve agents. Other long-term consequences of exposure to organophosphate pesticides are neuropsychiatric effects and possible EEG changes. The many studies of English and Japanese mustard factory workers establish repeated symptomatic exposures to mustard over a period of years as a causal factor in an increased incidence of airway cancer. The association between a single exposure to mustard and airway cancer is not as well established. The association between one-time mustard exposure and other chronic airway problems, such as chronic bronchitis, which is based on World War I data, seems more clearly established. Several eye diseases, such as chronic conjunctivitis, appear after an acute, usually severe, insult to the eye. In particular, delayed keratitis has appeared more than 25 years after the acute, severe lesion. The production of nonairway cancer by mustard has been demonstrated in animals, but scant evidence exists to implicate mustard as a causative factor in nonairway cancer in humans. Mustard causes chromosomal breakage and induces sister chromatid exchanges in man and has been classed as a mutagen. No data that implicate mustard as a reproductive toxin in man seem to be available, despite the many thousands of people exposed to mustard in the past 80 years.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.; Hurst, Charles G.1997
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Chapter 4: The Chemical Warfare Threat and the Military Healthcare ProviderThe military healthcare provider should be prepared to be the first to recognize military or civilian casualties of chemical warfare attack. This requires an informed understanding of the likelihood of chemical warfare agent use or threat, and it requires the ability to clearly recognize agent-exposure symptoms against a varying background of unrelated injury and stress behaviors. The healthcare provider should be informed, to the fullest extent possible, when to anticipate chemical warfare attack by hostile forces or terrorist activities. This requires consideration of an adversary with regard to political factors and motivation, chemical agent possession or access, chemical warfare offensive and defensive capabilities, and the strategic advantage to be realized through agent use. When individuals suspected to have been exposed to chemical warfare agents are encountered, initial recognition of the type of agent used may be facilitated through an understanding of tactical agent use, modes of agent dissemination, likely routes of casualty exposure to agent, and physical agent properties and other factors determining the persistence of these toxicants in the operating environment. Finally, to protect both the injured and medical personnel, casualty care must take place within a framework of decontamination both in the field and in forward medical support facilities.United States. Department of the Army. Office of the Surgeon GeneralTakafuji, Ernest T.; Kok, Allart B.1997
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Chapter 6: Pretreatment for Nerve Agent ExposureThe inadequacy of postexposure therapy for nerve agent casualties, particularly those with potentially lethal exposures to soman, has been of great concern. Development of pyridostigmine, a peripherally active carbamate compound, as a nerve agent pretreatment adjunct has substantially improved the ability of the U.S. military to protect its soldiers from the lethal effects of nerve agents. A major deficiency of this pretreatment program --that it does not protect the CNS against nerve agent-induced injury--may be overcome by postexposure administration of anticonvulsants. While centrally acting pretreatments offer more effective protection than does pyridostigmine, their development is limited because of their potential for impairing soldier performance. New research may provide a revolutionary advance in protection against nerve agents with biotechnologically derived pretreatments that bind or inactivate nerve agents in the circulation.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.; Dunn, Michael A.; Hackley, Brennie E., Jr.1997
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Chapter 1: Overview: Defense against the Effects of Chemical and Biological Warfare Agents"Gas! Gas!" This warning cry, so common in World War I, almost became real to U.S. forces again as they prepared to liberate Kuwait in late 1990. The threat of chemical, and even biological, warfare was foremost in the minds of U.S. military personnel during Operation Desert Shield, the preparation for the Persian Gulf War. Iraq was known to have a large stockpile of chemical weapons and had demonstrated during its conflict with Iran that it would use them. It was not until after the Persian Gulf War that the U.N. Special Commission on Iraq confirmed that Saddam Hussein also had biological agents loaded in weapons. The chemical and biological threats were major concerns to those in the military medical departments who would be called on to care for poisoned or infected casualties, possibly in a chemically contaminated environment. Fortunately the ground war of the Persian Gulf War (Operation Desert Storm) was brief, and even more fortunately, our adversary did not employ these weapons. Two lessons were learned from this conflict, lessons that should never be forgotten by those in the military. The first was that there are countries that have chemical and biological weapons, and there are other countries that might obtain or produce them. The second was that the U.S. military medical departments must be prepared at all times to treat both types of casualties. As long as potential adversaries exist, the U.S. military might face a chemical or biological battlefield. The breakup of the Soviet Union, and the consequent glut of biowarfare experts on the world employment market, may have actually increased the threat of biological proliferation. In addition to the recent experience in the Persian Gulf, a review of other events of the past 2 decades bears out this conclusion.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.; Franz, David R.1997
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Chapter 34: Trichothecene MycotoxinsTrichothecene mycotoxins are noted for their marked stability under different environmental conditions. On a weight-for-weight basis, they are less toxic than other toxins such as ricin, botulinum, and staphylococcal enterotoxin B, but trichothecene mycotoxins are proven lethal agents in warfare. Symptoms include vomiting, pain, weakness, dizziness, ataxia, anorexia, diarrhea, bleeding, skin redness, blistering, and gangrene, as well as shock and rapid death. Sensitive immunoassays and chemical procedures are available for the identification of trichothecene mycotoxins in biological samples, but no detection kits have been fielded. Prevention of exposure is the only current defense, with a protective mask and clothing worn when under attack. Previous successful lethal attacks have always occurred against unprotected civilians and soldiers. Skin decontamination with water and soap can be used effectively up to 6 hours after exposure. Experimental treatments for systemic toxicity are being investigated, but no therapy is available for humans.United States. Department of the Army. Office of the Surgeon GeneralWannemacher, Robert W., Jr.; Wiener, Stanley L.1997
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Chapter 30: Defense Against Toxin WeaponsProtecting soldiers on the battlefield from toxins --and replicating agents--is possible if we use our combined resources effectively. Physical countermeasures such as the protective mask, protective clothing, and decontamination capabilities exist and are effective. As we improve our battlefield detection systems, early warning of our soldiers may become a reality, at least in subpopulations within our forces. These assets, unlike most medical countermeasures, are generally generic and protect against most or all of the agents. Among the medical countermeasures, vaccines are available and effective for some of the most important agents, and therapies exist for others. Because of limited resources available to develop vaccines, diagnostic methodologies, and therapies, we can field specific medical countermeasures only to a relatively small group of threat agents. Our efforts in this area must be carefully focused. A third and complementary element of our defensive program must be good intelligence. Only through knowledge of specific threat agents, delivery systems, and national capabilities can we assure the effective development and use of our physical and medical countermeasures. Finally, our renewed understanding of the real strengths and weaknesses of toxins as weapons allows us to put them in perspective in educating our soldiers, removing much of the mystique--and associated fear--surrounding toxins. Knowledge of the threat thus reduces the threat to our soldiers.United States. Department of the Army. Office of the Surgeon GeneralFranz, David R.1997
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Chapter 33: Botulinum ToxinsThe seven serotypes of botulinum toxin produced by Clostridium botulinum are the most toxic substances known. They are associated with lethal food poisoning after the consumption of canned foods. This family of toxins was evaluated by the United States as a potential biological weapon in the 1960s and is believed to be an agent that could be used against our troops. Unlike other threat toxins, botulinum neurotoxin appears to cause the same disease after inhalation, oral ingestion, or injection. Death results from skeletal muscle paralysis and resultant ventilatory failure. Because of its extreme toxicity, the toxin typically cannot be identified in body fluids, other than nasal secretions, after inhalation of a lethal dose. The best diagnostic sample for immunologic identification of the toxin is from swabs taken from the nasal mucosa within 24 hours after inhalational exposure. Because of the small quantity of toxin protein needed to kill, botulinum toxin exposure does not typically induce an antibody response after exposure. Prophylactic administration of a licensed pentavalent vaccine fully protects laboratory animals from all routes of challenge. Passive immunotherapy with investigational hyperimmune plasma also prevents illness if it is administered before the onset of clinical intoxication.United States. Department of the Army. Office of the Surgeon GeneralFranz, David R.; Middlebrook, John L.1997
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Chapter 29: Viral Hemorrhagic FeversThe VHF agents are a taxonomically diverse group of RNA viruses that cause serious diseases with high morbidity and mortality. Their existence as endemic disease threats or their use in biological warfare could have a formidable impact on unit readiness. Significant human pathogens include the arenaviruses (Lassa, Junin, and Machupo viruses, the agents of Lassa fever and Argentinean and Bolivian hemorrhagic fevers, respectively). Bunyavirus pathogens include RVF virus, the agent of Rift Valley fever; C-CHF virus, the agent of Crimean- Congo hemorrhagic fever; and the hantaviruses. Filovirus pathogens include Marburg and Ebola viruses. The flaviviruses are arthropod-borne viruses and include the agents of yellow fever, dengue, Kyasanur Forest disease, and Omsk hemorrhagic fever. A viral hemorrhagic fever should be suspected in any patient who presents with a severe febrile illness and evidence of vascular involvement (subnormal blood pressure, postural hypotension, petechiae, easy bleeding, flushing of the face and chest, nondependent edema), and who has traveled to an area where the virus is known to occur, or where intelligence suggests a biological warfare threat. Patients with viral hemorrhagic fevers generally benefit from rapid, nontraumatic hospitalization to prevent unnecessary damage to the fragile capillary bed. Aspirin and other antiplatelet or anticlottingfactor drugs should be avoided. Secondary and concomitant infections including malaria should be sought and aggressively treated. The management of bleeding includes administration of fresh frozen plasma, clotting factor concentrates and platelets, and early use of heparin to control DIC. Fluids should be given cautiously, and asanguineous colloid or crystalloid solutions should be used. Multiple organ system support may be required. Ribavirin is an antiviral drug with efficacy for treatment of the arenaviruses and bunyaviruses. Passively administered antibody is also effective in therapy of some viral hemorrhagic fevers. The only licensed vaccine available for VHF agents is for yellow fever. Experimental vaccines exist for Junin, RVF, hantaan, and dengue viruses, but these will not be licensed in the near future.United States. Department of the Army. Office of the Surgeon GeneralJahrling, Peter B.1997
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Chapter 32: Ricin ToxinRicin is a large, moderately toxic, protein dichain toxin from the bean of the castor plant, Ricinis communis. It can be produced easily in relatively large quantities. Ricin was developed as a biological weapon by the United States and its allies during World War II. Although ricin is toxic by several routes, when inhaled as a respirable aerosol, it causes severe necrosis of the airways and increased permeability of the alveolar- capillary membrane. The inhalational route is presumed to be the likeliest threat on the battlefield. Death after inhalation of a lethal dose appears to be caused by hypoxemia resulting from massive pulmonary edema and alveolar flooding. Diagnosis can be confirmed through the use of enzymelinked immunosorbent assays of tissues or body fluids. Prophylactic administration of an investigational vaccine protects laboratory animals from inhalational and other routes of challenge.United States. Department of the Army. Office of the Surgeon GeneralFranz, David R.; Jaax, Nancy K.1997
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Chapter 31: Staphylococcal Enterotoxin B and Related Pyrogenic ToxinsThe staphylococcal enterotoxins are a family of superantigen protein toxins produced by strains of Staphylococcus aureus. Staphylococcal enterotoxin B (SEB), a toxin often associated with food poisoning, was weaponized as an incapacitating agent by the United States during in the 1960s. When inhaled as a respirable aerosol, SEB causes fever, severe respiratory distress, headache, and sometimes nausea and vomiting. The mechanism of intoxication is thought to be from a massive release of cytokines such as interferon-gamma, interleukin-6 and tumor necrosis factor-alpha. Diagnosis can be confirmed through the use of enzyme-linked immunosorbent assays of tissues or body fluids. Prophylactic administration of an investigational vaccine protects laboratory animals from inhalational challenge. Supportive care is useful in reducing toxicity in unprotected individuals.United States. Department of the Army. Office of the Surgeon GeneralUlrich, Robert G.1997
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Chapter 7: VesicantsA vesicant (i.e., an agent that produces vesicles or blisters) was first used as a chemical weapon on the battlefields of World War I; that same vesicant-- sulfur mustard--is still considered a major chemical agent. In the intervening years between World War I and today, there have been a number of recorded and suspected incidents of mustard use, culminating with the Iran-Iraq War in the 1980s. The military has considered vesicants to be major chemical warfare agents since 1917. Mustard, however, is the only vesicant known to have been used on the battlefield. Mustard and Lewisite, in much smaller amounts, are known to be in the stockpiles of other countries. Mustard was used on a large scale in World War I, causing a great number of casualties; it was also used during the Iran-Iraq War. Data from the Iran-Iraq War are scanty; however, data from World War I indicate that more than 95% of mustard casualties survived but most required lengthy hospitalizations. If mustard is ever used again, military medical personnel must be prepared to accept and care for large numbers of casualties, who will require long-term hospitalization.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.1997
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Chapter 9: Toxic Inhalational InjuryPulmonary toxic inhalants have been a military concern since the Age of Fire. Thucydides, in 423 BC, recorded the earliest belligerent use of a toxic inhalant. The Spartans used a burning mixture of pitch, naphtha, and sulfur to produce sulfur dioxide that was used in sieges of Athenian cities. There is scant reference in the literature to further military use of toxic inhalants until World War I. In early 1914, both the French and Germans investigated various tear gases, which were later employed. By early 1915, the German war effort expanded its gas research to include inhaled toxicants. As a result, on 22 April 1915, at Ypres, Belgium, the Germans released about 150 tons of chlorine gas along a 7,000-m battlefront within a 10-minute period. Although the exact number of injuries and deaths are unknown, this "new form" of warfare produced a degree of demoralization theretofore unseen. Although phosgene and chlorine have not been used militarily since 1918, vast amounts are produced annually for use in the industrial sector. The potential for accidental or deliberate exposure to a toxic inhalant exists, and military personnel should be prepared. During World War I, the number and types of pulmonary toxicants available to the military increased substantially. At least 14 different respiratory agents were used, as well as obscurants (smokes), harassing agents (chloracetone), and vesicants (mustard) that could cause pulmonary injury. Today, only a handful of these toxicants still exist in stockpiles around the world, but several, such as chlorine and phosgene, are currently produced in large quantities for industrial purposes. Whether produced for military or industrial uses, these chemical agents pose a very real threat to military personnel. Toxic inhalational injury poses a 2-fold problem for military personnel: 1. No specific therapy exists for impeding or reversing toxic inhalant exposures. 2. Toxic inhalational injury can cause large numbers of casualties that can significantly burden medical facilities. The importance of chronic health problems that occur postexposure to toxic inhalants is a contentious subject because of the nebulous signs and symptoms that mimic degenerative diseases, such as emphysema, common to the general population.United States. Department of the Army. Office of the Surgeon GeneralUrbanetti, John S.1997
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Chapter 11: Incapacitating AgentsIncapacitating agents, capable of temporarily preventing military personnel from performing their duties (without permanent injury), have a long and colorful history. For a variety of reasons, they have not generally been used in overt warfare in the 20th century. Preference for conventional lethal weapons by most aggressors, and the many uncertainties applying to their use by friendly nations, have led to their elimination from the United States's arsenal. However, in the attempt to find an incapacitating agent that would meet the numerous constraints imposed by practical and political concerns, many studies were conducted, especially by the U.S. Army, during the 1960s. Although an ideal incapacitating agent was never found, much was learned from the search. Of all known psychochemical options, anticholinergics appear to be the most feasible for military use. 3-Quinuclidinyl benzilate (BZ) or a related potent glycolate seem to be the most likely candidates among the many that have been studied. Following an absorbed dose of less than 1 mg, BZ produces an acute brain syndrome, best described as delirium, that lasts 2 to 3 days. Reversal of the effects of BZ by physostigmine and other anticholinesterase agents has been clearly demonstrated to be both effective and safe when properly used in otherwise healthy individuals. The benefits and methods of use of physostigmine were brought to the attention of modern medicine by U.S. Army medical officers, who conducted these studies. Incapacitation produced by less likely candidates such as LSD and other indole derivatives, psychedelic phenethylamines, and potent opioids is theoretically possible, but it is unlikely that any of these compounds would be employed militarily. Covert use, which is logistically easier to accomplish and has fewer constraints, opens a broader spectrum of possibilities. This, however, is a concept that involves considerations that generally extend beyond the scope of chemical warfare.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.; Ketchum, James S.1997
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Chapter 12: Riot Control AgentsThree types of riot control agents are recognized: lacrimators, sternutators, and vomiting agents. Because these compounds- CS, CN, DM, CR, and CA- have a number of characteristics in common, they are grouped together in this chapter. Riot control agents are intended to harass or to cause temporary incapacitation. Their intended target might be the foe in an armed conflict--with the limitations outlined above--or rioters in a civil disturbance. Much evidence suggests that riot control agents are safe if they are used as intended and if the response is as intended. When they are not used as intended, and the response is not as intended, how ever, there may be devastating consequences (e.g., the deaths of the Branch Davidians at Waco, Tex.). Almost all of the reported adverse effects have resulted from indiscriminate use of weapons containing riot control agents or from resistance to the effects of the compounds, which increases the amount of exposure. Sometimes injury results from the effects of the delivery system of the weapon rather than from the compound; these two sources of injury should not be confused. Indiscriminate or uncontrolled use of CS, or any riot control compound, is obviously not desired, nor is it necessary in circumstances in which a better, less drastic solution is possible. But the use of CS or CN might be more benign than the use of more deadly alternatives in desperate circumstances. As the data clearly suggest, CS is a relatively safe compound when used as intended.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.1997
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Chapter 10: Cyanide PoisoningCyanide, an ancient compound, is often associated with murders and assassinations. Cyanide, long considered a toxic, deadly substance, has been used as a poison for thousands of years. Because of the high amount needed to cause death and the inefficient weapons in which it was used, cyanide was not an effective chemical weapon in World War I; however, it was possibly used by Iraq against the Kurds in the Iran-Iraq War during the late 1980s. It was not highly successful as a chemical warfare agent in World War I, possibly because of the way it was delivered. Cyanide causes intracellular hypoxia by inhibiting the intracellular electron transport mechanism, the cytochrome enzymes. After inhalation of a large amount of cyanide--as either hydrocyanic acid or cyanogen chloride--the onset of effects is within seconds, symptoms are few, physical findings are scanty, and death occurs within minutes. The antidotes used in the United States, sodium nitrite and sodium thiosulfate, are quite effective if given before cessation of cardiac activity. Antidotes are effective if administered in time. Cyanide is ubiquitous. It is present in some foods, in the products of combustion of synthetic materials, and is widely used in industry. Much of the cyanide used is in the form of salts, such as sodium, potassium, or calcium cyanide. The cyanides of military interest are the volatile liquids hydrocyanic acid (hydrogen cyanide, HCN; North American Treaty Organization [NATO] designation: AC) and cyanogen chloride (NATO designation: CK) (Table 10-1 in this document). Although substances containing cyanide had been used for centuries as poisons, it was not until 1782 that cyanide itself was identified. It was first isolated by the Swedish chemist Scheele, who later may have died from cyanide poisoning in a laboratory accident.United States. Department of the Army. Office of the Surgeon GeneralBaskin, Steven I.; Brewer, Thomas G.1997
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Chapter 14: Triage of Chemical CasualtiesTriage of casualties of chemical agents is based on the same principles as the triage of conventional casualties. The triage officer tries to provide immediate care to those who need it to survive; he sets aside temporarily or delays treatment of those who have minor injuries or do not need immediate medical intervention; and he does not use limited medical assets on the hopelessly injured. At the first echelon of medical care on a battlefield, medical capabilities are very limited. When chemical agents are present or suspected, medical capabilities are further diminished because early care must be given while the medical care provider and casualty are in protective clothing. Decontamination, a time-consuming process, must be carried out before the casualty receives more definitive care, even at this level. At the rear echelons of care--or at a hospital in peacetime--medical capabilities are much greater and decontamination has already been accomplished before the casualty enters for treatment. Triage is a matter of judgment by the triage officer. This judgment should be based on knowledge of medical assets, the casualty load, and, at least at unit-level MTFs, the evacuation process. Most importantly, the triage officer must have full knowledge of the natural course of an injury and its potential complications.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.1997
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Chapter 13: Field Management of Chemical CasualtiesField management of a contaminated casualty or of a casualty in a contaminated environment is cumbersome and manpower-intensive. In front of each medical care facility, from battalion aid station to field hospital, there must be a casualty-receiving station if casualties are contaminated, or if casualties are entering from a contaminated area. In this station, casualties are (a) triaged, (b) given the emergency care that can be provided with both casualty and medical care provider encapsulated in protective garments, (c) decontaminated, and then (d) taken into a noncontaminated--or clean--area for further care. At this stage or after the initial triage, the casualty may be evacuated to a higher-echelon facility, depending on the needs of the casualty and on the resources available. Initial triage is greatly hampered by the partial loss of the senses of sight and touch because of the protective garments. Initial medical care in the contaminated area is rudimentary because of potential contamination on the casualty and because of the protective equipment. Decontamination of a casualty takes about 10 to 20 minutes.United States. Department of the Army. Office of the Surgeon GeneralSidell, Frederick R.1997
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Chapter 15: DecontaminationDecontamination at the MTF is directed toward (1) eliminating any chemical agent transferred to the patient during removal of protective clothing; (2) decontaminating or containing of contaminated clothing and personal equipment; and (3) maintaining an uncontaminated MTF. Current doctrine specifies the use of 0.5% hypochlorite solution for chemical or biological skin contamination or the M291 kit for chemically contaminated skin. Fabric and other foreign bodies that have been introduced into a wound can sequester and slowly release chemical agent, presenting a liquid hazard to both the patient and medical personnel. Dry biological agent could be a hazard through secondary aerosolization. Adequate liquid decontamination will mitigate this hazard. There is no vapor hazard, and protective masks are not necessary for surgical personnel.United States. Department of the Army. Office of the Surgeon GeneralHurst, Charles G.1997
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Chapter 16: Chemical Defense EquipmentOne criterion for the selection and use of protective equipment items is the need for joint service use, although there are some differences between the missions of air and ground crews that must be accommodated. This chapter is not intended to be all-encompassing in chemical defense equipment; rather, it is intended to describe the items and operations that are of greatest interest to the medical community. The following sections address each of the protection areas described above in detail, with the current equipment items featured and items in development that are designed to overcome the deficiencies of present equipment briefly described. Sufficient technical data are included to allow the healthcare professional to become familiar with the operation, components, and the limitations of the present chemical defense equipment. Should the interested reader desire more detail on chemical defense equipment, several sources are available. First, the written references and expert consultants to this chapter are sources of vast amounts of information. Possibly of more value to the healthcare professional is the nuclear, biological, and chemical (NBC) officer who is an integral part of each combat element and who is available to provide detailed advice as well as hands-on assistance. As threats of chemical and biological warfare become more routine, it is imperative that soldiers can wear their protective gear. Frequent practice should increase comfort and decrease problems with claustrophobia and embarrassment. In those who cannot initially tolerate the gas masks, treatment should be initiated as close to the front lines as possible, to minimize casualties in training and in combat.United States. Department of the Army. Office of the Surgeon GeneralO'Hern, Michael R.; Dashiell, Thomas R., 1927-; Tracy, Mary Frances1997
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Biological Warfare ThreatInternational proliferation of biological warfare programs broadens the range of agents that members of the U.S. armed forces may encounter. Ironically, the modernization of many Third World nations--with the subsequent development of industrial, medical, pharmaceutical, and agricultural facilities needed to support these advancing societies-- provides the basis for development of a biological weapons program, should a nation decide to pursue such an endeavor. A biological weapons program can easily be concealed within legitimate research-and-development and industrial programs, even by countries that are signatories to the 1972 Biological Weapons Convention. Actions such as these are grave threats to our national security. Biological warfare agents may be more potent than the most lethal chemical warfare agents, and provide a broader area coverage per pound of payload than any other weapons system. The proliferation of technology and of scientific progress in biochemistry and biotechnology has simplified production requirements and provided the opportunity for the creation of exotic agents. This could involve the tailoring of pathogenic microorganisms capable of creating a novel disease, perhaps on an epidemic scale. Humans need not be the only target of biological weapons. These weapons might be meant to attack a country's revenue or food crop, animal herds, or even a supply of a material that is vital for revenue or defense. Despite the end of the Cold War, the United States still faces serious national security issues. One at the forefront is the issue of the proliferation of biological weapons, especially in Third World nations that have compelling military, technical, economic, and political incentives to pursue this capability. The use of biological agents in future wars and actions by terrorists--foreign and domestic--is a legitimate issue of concern. Resolution of this problem should be given the highest priority.United States. Department of the Army. Office of the Surgeon GeneralCaudle, Lester C., III1997
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Chapter 17: Healthcare and the Chemical Surety MissionThe unique challenges of chemical warfare agents, aging munitions, and protecting worker health in a chemical environment can prove a rewarding experience for healthcare providers. The personnel reliability program places numerous safety and administrative demands that require that the physician acquire knowledge in occupational medicine that many physicians never experience. Unlike many clinicians, the IMA is thrust into an environment that requires interaction with multiple professional groups. Coordination with industrial hygienists and safety officers will result in an awareness of the workplace and the work conditions that is seldom appreciated by other physicians. Designing a medical surveillance program to prevent illness and injury is seldom attempted by most physicians in clinical practice. This secondary preventive measure will augment and reinforce the primary preventive efforts of safety and industrial hygiene measures. Appropriate surveillance requires a thorough knowledge of the chemical agents. Requisite information is available through mandatory courses and on-the-job training. The chemical demilitarization process places additional demands on U.S. Army Medical Department personnel. In addition to the many responsibilities inherent to the chemical surety mission, the IMA may be challenged with risk communication. Many of the civilians living near depot storage facilities do not approve of the plan to incinerate the 30,000 tons of agents stored at these sites. Healthcare providers can play an important role in providing information and building confidence in the U.S. Army's ability to safely destroy these agents through incineration.United States. Department of the Army. Office of the Surgeon GeneralGum, Robert1997
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Chapter 20: Use of Biological WeaponsSince initial symptoms resulting from a biological warfare agent may often be indistinguishable from those produced by endemic infections, a biological weapon may be capable of overcoming a military force before the presence of the agent is even suspected. When one member of a unit falls victim, others may still be incubating the disease. Troops deployed to foreign lands are at greater risk for exotic endemic disease agents, since they may lack natural immunity. Therefore, a biological warfare attack may not even be suspected after the first casualties have presented to medical personnel. Finally, the psychological and demoralizing impact of the sinister use of a lethal infection or toxin cannot be underestimated. Many biological agents, including bacteria, viruses, and toxins, can be used as biological weapons. The respective chapters in this textbook contain detailed discussions of these pathogens and toxins as biological weapons. Biological warfare could be used against the United States in a theater of operations or against our civilian populations in any number of realistic scenarios. The medical consequences of such use are potentially catastrophic unless measures are taken to minimize the potential impact of biological warfare agents on our people. Proper planning for terrorist as well as military scenarios, better and more realistic training under NBC conditions, adequate environmental detection and monitoring, improved vaccines and prophylactic drugs for our military, and sensitive and specific medical diagnostics are all pathways toward defending against the possible nightmare of biological attack.United States. Department of the Army. Office of the Surgeon GeneralEitzen, Edward1997
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Chapter 19: The U.S. Biological Warfare and Biological Defense ProgramsAlthough biological agents have been used in warfare for centuries to produce death or disease in humans, animals, or plants, the United States did not begin a biological warfare offensive program until 1941. It was concern about the Japanese biological warfare threat that motivated the United States to begin to develop biological weapons. During the next 28 years, the United States initiative evolved into an effective, military-driven research and acquisition program, shrouded in controversy and secrecy. Most research and development was done at Fort Detrick, Maryland, while production and testing occurred at Pine Bluff, Arkansas, and Dugway Proving Ground, Utah. Field testing was done secretly and successfully with simulants and actual agents disseminated over wide areas. A small defensive effort paralleled the weapons development and production program. With the presidential decision in 1969 to halt offensive biological weapons production, and the agreement in 1972 at the international Biological Weapons Convention never to develop, produce, stockpile, or retain biological agents or toxins, the program became entirely defensive, with medical and nonmedical components. The U.S. Biological Defense Research Program exists today, conducting research to develop physical and medical countermeasures to protect service members and civilians from the threat of modern biological warfare.United States. Department of the Army. Office of the Surgeon GeneralFranz, David R.; Takafuji, Ernest T.; Parrott, Cheryl D.1997
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Chapter 18: Historical Overview of Biological WarfareThe possibility that biological weapons will be used against us is no longer unthinkable. Until recently, medical officers and other healthcare practitioners may have considered this topic more suitable for academic than practical pursuit. The fact is, however, that biological agents have been used as weapons since antiquity, and the threat that modern weapons will be used is real. In fact, Saddam Hussein's aggression in the Persian Gulf War may have provided our nation with a wake-up call. The importance of education regarding this unpalatable subject cannot be overestimated. Before our soldiers deploy again against an aggressor likely to use biological weapons, our military healthcare providers need to be confident that they understand both the threat and the medical countermeasures to the threat. This chapter and the ones that follow will help meet that need. The threat of biological warfare has increased over the past 2 decades, with a number of countries working on offensive use of these agents. The extensive program of the former Soviet Union is now controlled largely by Russia. Admitting that a biological warfare program existed until early 1992--nearly 20 years after the USSR signed the Biological Weapons Convention in 1972--Russian president Boris Yeltsin has stated23 that he will put an end to further offensive biological research. However, the degree to which the program has been scaled back is not known. There is intense concern in the West about the possibility of proliferation or enhancement of offensive programs in countries hostile to the western democracies, due to the potential hiring of expatriate Russian scientists. There is also a certain amount of concern over the possibility that terrorists might use biological agents to threaten either military or civilian populations. Certainly the threat that biological weapons will be used against U.S. military forces is broader and more likely in various geographic scenarios now than it has been at any point in our history.United States. Department of the Army. Office of the Surgeon GeneralEitzen, Edward; Takafuji, Ernest T.1997
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Chapter 28: Viral EncephalitidesThe equine encephalomyelitis viruses consist of three antigenically related viruses within the Alphavirus genus of the family Togaviridae: Venezuelan equine encephalomyelitis (VEE), western equine encephalomyelitis (WEE), and eastern equine encephalomyelitis (EEE). These viruses are vectored in nature by various species of mosquitoes and cause periodic epizootics among equines. Infection of equines with virulent strains of any these viruses produces a similar clinical course of severe encephalitis with high mortality. However, the clinical course following infection of humans differs. EEE is the most severe of the arbovirus encephalitides, with case fatality rates of 50% to 70%. WEE virus is generally less virulent for adults, but the infection commonly produces severe encephalitis in children, with case fatality rates approaching 10%. In contrast, encephalitis is rare following VEE virus infection, but essentially all infected individuals develop a prostrating syndrome of high fever, headache, malaise, and prolonged convalescence. Although natural infections are acquired by mosquito bite, these viruses are also highly infectious in low doses as aerosols. They can be produced in large amounts in inexpensive and unsophisticated systems, are relatively stable, and are readily amenable to genetic manipulation. For these reasons, the equine encephalomyelitis viruses are classic biological warfare threats. No specific therapy exists for infections caused by these viruses. A live-attenuated vaccine for VEE (TC-83) and inactivated vaccines for VEE, EEE, and WEE have been developed and are used under IND status. Although these vaccines are useful in protecting at-risk individuals, they have certain disadvantages, and improved vaccines are under development.United States. Department of the Army. Office of the Surgeon GeneralSmith, Jonathan F.1997
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Chapter 23: PlaguePlague is a zoonotic infection caused by the Gram-negative bacillus Yersinia pestis. Three great human pandemics have been responsible for more deaths than any other infectious agent in history. Plague is maintained in nature, predominantly in urban and sylvatic rodents, by a flea vector. Humans are not necessary for persistence of the organism, and we acquire the disease from animal fleas, contact with infected animals, or, rarely, from other humans, via aerosol or direct contact with infected secretions. To be able to differentiate endemic disease from plague used in biological warfare, medical officers must understand the typical way in which humans contract plague in nature. First, a dieoff of animals in the mammalian reservoir that harbors bacteria-infected fleas will occur. Second, troops who have been in close proximity to such infected mammals will become infected. By contrast, in the most likely biological warfare scenario, plague would be spread via aerosol. A rapid, person-to-person spread of fulminant pneumonia, characterized by blood-tinged sputum, would then ensue. If, on the other hand, an enemy force were to release fleas infected with Y pestis, then soldiers would present with classic bubonic plague before a die-off in the local mammalian reservoir occurred. The most common form of the disease is bubonic plague, characterized by painful lymphadenopathy and severe constitutional symptoms of fever, chills, and headache. Septicemic plague without localized lymphadenopathy occurs less commonly and is difficult to diagnose. Secondary pneumonia may follow either the bubonic or the septicemic form. Primary pneumonic plague is spread by airborne transmission, when aerosols from an infected human or animal are inhaled. Diagnosis is established by isolating the organism from blood or other tissues. Rapid diagnosis may be made with fluorescent antibody stains of sputum or tissue specimens. Patients should be isolated and treated with aminoglycosides, preferably streptomycin, plus chloramphenicol when meningitis is suspected or shock is present. A licensed, killed, whole-cell vaccine is available to protect humans against bubonic, but not against primary pneumonic, plague.United States. Department of the Army. Office of the Surgeon GeneralFriedlander, A.; McGovern, Thomas W.1997