Department of Veterans Affairs

1. Department of Veterans Affairs Victoria A. Cassano, MD, MPH Acting Chief Consultant Environmental Health Strategic Healthcare Group

2. SARIN GASPESTICIDES & ANTIDOTES Was I exposed? Was the cure worse?

3. Pesticides • Organochlorines • Organophosphates • Pyrethrins • Carbamates

4. Pesticides • Pesticides are preparations used to control or destroy organisms that interfere with man's agricultural, environmental or amenity requirements • They are used in the form of liquid preparations, powders or granules

5. Pesticides - Organochlorines • DDT ( 1,1-bis[p-chlorophy]2,2,2 trichloroethane) • Acute toxicity in mammals low • Accumulates in environment deposited in lipids of mammals, birds and fish • Carcinogenic • Acute toxicity leading to convulsions only with ingestion • Banned in 1973 • DDE • Hepatotoxic • Benzene Hexachloride (Lindane) • ? Aplastic anemia • Dieldrin, Aldrin, Endrin and Chlordane

6. Pesticides – Carbamates • CO2NH3 – Carbamic Acid • No Chlorine • No Phosphates • Trade name – SEVIN • Anticholinesterase Inhibitor • Rapidly reversible inhibition

7. Pesticides - Organophosphates • Irriversible anticholinesterase activity • Parathion • Malathion • Phosdrin • Dichlorvos • SARIN (CH3)2CHO-PO-CH3-F * • Most toxic of the “nerve gases”

8. Organochlorines Nausea Vomiting Restlessness Tremor Apprehension Convulsions Coma Respiratory Failure Death Organophosphates MILD: Headache, dizziness, weakness, anxiety, miosis, loss of visual acuity MODERATE: Nausea, salivation, lacrimation, abdominal cramps, vomiting, sweating, slow pulse, muscle tremors SEVERE: diarrhea, pinpoint & non-reactive pupils, respiratory difficulty, pulmonary edema, cyanosis, loss of sphincter control, convulsions, coma, death Pesticides- Acute Effects

9. SARIN • Most toxic nerve agent (until VX) • 1,000 X more toxic than parathion • LCt50 : vapor: 100 mg.min/m3 • LD50 : liquid: 1,700 mg (skin)

10. SARIN Skin exposure: • Mild: • increased sweating at site • Muscular fasciculation at site • Moderate: same as above+ • Nausea, vomiting, diarrhea, generalized weakness • Severe: Same as above + • LOC, Convulsions, generalized fasciculations, flaccid paralysis, apnea, generalizes secretions, loss of sphincter control

11. Was I exposed?

12. Potential US Troop Exposure • Khamisiyah – March 1991 • Destruction of enemy munitions in Occupied areas of Iraq • US 37th and 307th engineering Battalions • Sarin and cyclosarin • Detectors did not go off, sensitive only to lethal or near lethal concentrations • UNSCOM confirmed presence of nerve agents in October 1991 • Modeling indicates that noticible effects might have been seen within 25km of the demolition site • Approximately 20,000 troops were within 50 miles • None reported acute effects in DOD mailed questionnaire • Al Muthanna • Muhammadiyat

13. Potential US Troop Exposure • First noticeable effects • Ct : 1mg-min/m3 • Watery eyes, runny nose, sweating, twitching, • General population level • Ct : 0.01296 mg-min/m3 • “General population including children and older people can remain for 72 hours with no effects” (i.e. acute effects) • 99,000 troops may have been exposed between these two levels.

14. Pyridostygmine Bromide (PB) • Peripherally Acting Carbamate Compound • Penetrates poorly into the CNS • Used in the therapy of neurological disorders where inhibition of synaptic AChE is clinically beneficial. • In large doses it mimics the peripheral effects of organophosphate nerve agents • Does not allow the irreversible nerve agents to bind to Acetylcholinesterase • PB + atropine + 2-PAM chloride showed greater protection than atropine + 2- PAM CL alone • It is an essential pretreatment adjunct for nerve agent threats; with target inhibition of AChE of 20 to 40%. (30 mg dose). • US forces were instructed to use PB only when a nerve agent attack was assessed to be imminent.

15. DEET • N, N, Diethyl-meta-toluimide • Is an insect repellant, not a pesticide • Developed by the Army in 1946 • Released to general public in 1957 • EPA Assessment • Used by 1/3 of the population • Normal usage is not considered hazardous to the general public • Long term exposure is not expected* • This differs with how DEET was/is used by soldiers in SW Asia

16. Is the cure worse?

17. fromDulce and Decorum ~ Lt Wilfred Owen, 1918 Gas! Gas! Quick, boys ---- An ecstasy of fumbling, Fitting the clumsy helmets just in time; But someone still was yelling out and stumbling And flound’ring like a man in fire or lime… Dim, through the misty panes and thick green light, As under a green sea, I saw him drowning. In all my dreams, before my helpless sight, He plunges at me, guttering, choking, drowning.

18. Summary • The primary purpose of the military is to maintain National security and • When directed by Congress and the Commander In Chief to prosecute a War • The primary purpose of the medical departments of the military in time of war is to maintain the fighting force • While more precautions can, should and are being taken, the readiness and strength of the fighting force can never be subordinated to the potential for long term sequelae of combat. • It is the Department of Veteran’s Affairs’ mission to care for those who have born the burden of our wars. • We will continue to elucidate the health outcomes in our combat Veterans and strive to find ways to treat them effectively.

19. Thank you! Questions???