Chemical and Biological Warfare Agents

1. Chemical and Biological Warfare Agents Charles Stewart MD FACEP

2. Thinking Out of The Box

3. Unrestricted warfare “With technological developments being in the process of striving to increase the types of weapons, a breakthrough in our thinking can open up the domain of the weapons kingdom at one stroke.”

4. Unrestricted Warfare is a Way of Thinking Out of the Box…

5. Unrestricted warfare “The new concept of weapons will cause ordinary people and military men alike to be greatly astonished at the fact that commonplace things that are close to them can also become weapons with which to engage in war. We believe that some morning people will awake to discover with surprise that quite a few gentle and kind things have begun to have offensive and lethal characteristics.”

6. Unrestricted warfare “It means that all weapons and technology can be superimposed at will, it means that all the boundaries lying between the two worlds of war and non-war, of military and non-military, will be totally destroyed.”

7. Unrestricted Warfare Qiao Liang and Wang Xiangsui Beijing: PLA Literature and Arts Publishing House, February 1999

8. Realism in Theater • Are we sufficiently prepared for the Right Threats? • Some other possible problems • NIH. –Not invented here • Media “guidance“ does not actually define a real threat. • Politicians often “react” and nay not properly plan for real threats • “Security” may make us less secure • Simple solutions don’t always solve complex problems.

9. What Should We Really Plan For? • Explosives • Flammable agents • Chemical agents • Biological Agents • Radiological dispersion weapons • Nuclear weapons • Snipers? All of them are possible threats !

10. Bombings are still the single most common form of terrorism • Conventional explosives are easy to get and easy to use. • Look for new ways to make and deliver them.

11. Types of terror attacks?Think Bombs!

12. Terrorist threat of explosives • Readily available • Predictable • Familiar effects • Abundant training available • Abundant information available • No difficulty with delivery

13. Asymmetric Warfare • Them: • 4 small crews • 100% “ martyrs” • Us: • More than 4000 direct casualties • 100’s of millions of $$ in damages • Massive damage to tourism and transportation industries

14. Law of unintended consequences • Lessons learned • Big missions can cause big consequences but provoke large responses • Little missions can cause big consequences with minimal risks • Anthrax or sniper model attacks • Does this mean that new incidents will be small in scope with maximum media impact? • Possibly

15. “Pearl Harbor” syndrome fully activated Secondary losses Loss of safe haven Afghanistan Iraq? System degradation Financial support degradation Law of unintended consequences

16. Potential Terrorist Targets • Critical facilities and infrastructure • Congress • Presidential staff • Supreme Court • Enclosed spaces • Large crowds (high profile events) • Facilities of interest to terrorists’ cause

17. In 2001, They Planned for at Least 3 and Possibly 4 Targets ?

18. In 2003, They Chose 3 Targets in Saudi Arabia

19. Terrorist threat of snipers • Weapons are readily available in almost all countries • Predictable • Effects familiar to EMS • Absolutely no difficulty with delivery • High media impact

20. Terrorist threat of snipers • Look at how two poorly trained and poorly equipped snipers affected 3 states in 2002 • 10 dead,3 injured • Think about how two or three teams of well trained snipers would be able to hurt us. • Has your EMS unit discussed/gamed/planned how to handle this type of terrorism?

21. Terrorist Threat of Chemical and Biological Agents • Ideal weapons of terrorism • Easily and cheaply made • Easily delivered • Rapidly manufactured • Technical information not “hot” • Political effects far beyond local casualties

22. Terrorist Threat of Incendiary Agents • Readily available • Predictable • Familiar effects • Abundant training available • Abundant information available • No difficulty delivering

23. Terrorist Threat of Nuclear Weapons • Not easily available • Fairly predictable • Great difficulty with delivery?? • Unfamiliar effects to most EMS • Abundant training available • Abundant information available • Readily detected ? • Closely controlled

24. Terrorist Threat of Radiological Weapons • Moderately available • Fairly predictable • Unfamiliar effects to most EMS • Abundant training available • Abundant information available • No difficulty with delivery • Readily detected • This is the easiest type of terrorism to detect! • Media hype expected

25. Radiologic Dispersal Weapons • Great media hype • Probably a small number of actual casualties • A quantity of sufficiently radioactive agent to cause real damage must: • Be set up as a fine particle (ground) • Transported to the area where it is to be used • Shielded from detection • This is not an easy set of tasks

26. Chemical and biological weapons are simply tools of unrestricted warfare

27. Terrorist Threat of Chemical Weapons • Moderately available • Fairly predictable • Unfamiliar effects to most EMS ? • Abundant training available • Abundant information available • Readily detected ?? • No difficulty with delivery

28. Simplistic solutions? • Decontamination –wash them all down with water? • Simple, easily implemented solution • Particularly effective for Sarin

29. Simplistic solutions? • Neglects fact that hydrolysis is not always effective or beneficial • Water is not particularly effective for Vx and other oily or thickened Agents? • Thickened Soman was in Russian inventory. • Vx is hydrolyzed to EA2192 • Water actually makes VX into a far more toxic and longer lasting substance EA2192 = Diethyl methylphosphonate, 2 diisopropylaminoethyl mercaptan, ethyl hydrogen methyl-phosphonate, bis(ethylmethylphosphonic)anhydride, bis S- (2-diisopropylaminoethyl) methylphosphononodithiote.

30. Simplistic solutions? • Bleach is bad ? • GRAS – generally recognized as safe! • Theoretically could consume 4 oz with no ill effects. • Hundreds of children have done so. • Bleach is a better decontamination agent than water • Much more rapid than water • Known activity against mustard, Soman, and VX-(military evidence in 50’s)

31. Simplistic solutions? • Water is not particularly effective for mustard • Europeans found bleach and sodium thiosufate to be more effective • No experience at all with water decontamination of “dusty” agents • Dusty mustard • Dusty Soman and Sarin

32. Decon Shower

33. Simplistic solutions? • Water will dilute and render safe this substance by lowering the concentration so that no significant downstream damage will occur? • Sarin – probably -volatile and non persistent • VX-???-long lived toxic hydrolysis products • Soman-??? • Mustard -???

34. Downstream safety ?

35. Dusty Agents • Combination of a chemical warfare agent with a very finely divided silica or talc powder to make a particulate aerosol • Civilian technology • Ortho Ant-Stop is an organophosphate in an inert carrier

36. Dusty mustard • Enhanced penetration of protective equipment • Goes under MOPP gear • “May” penetrate Level A PPE • Insufficient data exists to substantiate this statement • More rapid and enhanced pulmonary effect of mustard on unprotected

37. Dusty VX –Sarin –Soman • Enhanced penetration of protective equipment • Goes under MOPP gear • “May” penetrate Level A PPE* • More rapid and enhanced pulmonary absorption of VX on unprotected • “May” give a picture more like Sarin* • “May” make Sarin or Soman less volatile* *Insufficient data exists to substantiate this statement

38. Dusty Agents • Original Solution • ”WHILE EMPHASIZING THAT THERE IS NO EVIDENCE THAT IRAQ HAS DEVELOPED A DUSTY V-AGENT, FATALITIES RANGING FROM 3 TO 38 PERCENT ARE PROJECTED FOR THE SAME CONCENTRATIONS CITED ABOVE FOR TROOPS IN FULL MOPP IF SUCH AN AGENT WERE USED. USE OF THE PONCHO OVER THE MOPP GEAR IS EXPECTED TO REDUCE THESE PROJECTED CASUALTIES TO NEAR ZERO EVEN FOR A DUSTY NERVE AGENT. “

39. Dusty Agents • One senses that the prior recommendation was a desperate attempt to offer reassurance and a temporary “solution” for the troops. • Certainty, an open flapping poncho would offer no substantial improvement in chemical threat protection

40. SERPACWA • Better solution took 8 years to develop • Skin Exposure Reduction Paste Against Chemical Warfare Agents • Paste contains a perfluoroalkylpolyether (PFAPE) oil as a base polymer and polytetrafluoroethylene (Teflon polymer) dispersed within the base oil • ATSP soon to come

41. Simplistic solutions? • Everybody needs to be in Level A-B-C gear for personal protection • Governmental recommendations? • OSHA? • OPP gear is, at best, level C protection • Splash-Resistant over suit • Purified air (Negative Pressure) Protective mask • Turn-out gear +SCBA = 30 minutes protection? I don’t know the “ Right” answer to this question.

42. MOPP

43. Chemical Threats –NIH Problem • What is best cyanide antidote? • ? Lilly cyanide kit? • Expensive • Awkward to use • Dangerous to peds

44. Chemical Threats –NIH Problem • Hydroxycobalamin • NlH? • Vitamin B12 • Widely available and quite cheap • Not FDA approved for this • Kelocyanor? • NIH? • Available and widely used in Europe • Pricy?

45. Terrorist Threat of Biowar Agents • We were assured that biological agents were poor weapons of terrorism?? • Unpredictable • Weather • Lifespan (survivability) ? • Few good studies on effectiveness • Stigma • Difficulty with delivery ??

46. Terrorist Threat of Biowar Agents • We were assured that biological agents were poor weapons of terrorism?? • Unpredictable • Weather • Lifespan (survivability) ? • Few good studies on effectiveness • Stigma • Difficulty with delivery ??

47. We Were Expecting “ The Big One”...

48. We Got … • Historically most episodes of terrorism are rather small affairs… • This is a principle of asymmetric warfare… • Think about the confusion generated by …

49. Why Bioweapons? - Other Advantages • Undetectable by usual means • Remote effect (time-lag) • Perpetrator can leave scene • Widespread effect before discovery • Flexible • Covert vs Overt • Small scale vs large scale • Small amounts can inspire significant terror

50. Real Threat…or Fancy Fiction • Delivery will be a problem???