Chemical Agents of Facultyadph.org/ALPHTN/assets/356chemicalhandouts.pdf · biological agents. • Professional association of physicians with recognized expertise and board certification

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Chemical Agents ofOpportunity:

The Medical and PsychologicalConsequences of TICs and TIMs

Satellite ConferenceThursday, August 12, 2004

12:00-1:30 p.m. (Central Time)

Produced by the Alabama Department of Public HealthVideo Communications Division

Chemical Agents ofOpportunity:

The Medical and PsychologicalConsequences of TICs and TIMs

Satellite ConferenceThursday, August 12, 2004


Produced by the Alabama Department of Public HealthVideo Communications Division

FacultyFaculty

Erica L. Liebelt, MD, FACMTAssociate Professor of Pediatrics and

Emergency MedicineUniversity of Alabama

School of MedicineDirector, Medical Toxicology Services

University of Alabama Hospitals

Erica L. Liebelt, MD, FACMTAssociate Professor of Pediatrics and

Emergency MedicineUniversity of Alabama

School of MedicineDirector, Medical Toxicology Services

University of Alabama Hospitals

ObjectivesObjectives

• Understand the concept of chemicalagents of opportunity, ToxicIndustrial Chemicals (TICs) and ToxicIndustrial Materials (TIMs), andappreciate the basis for increasedpublic health preparedness.

• Identify chemical agents ofopportunity that could be used byterrorists and different modalities bywhich they can be distributed orreleased.

• Understand the concept of chemicalagents of opportunity, ToxicIndustrial Chemicals (TICs) and ToxicIndustrial Materials (TIMs), andappreciate the basis for increasedpublic health preparedness.

• Identify chemical agents ofopportunity that could be used byterrorists and different modalities bywhich they can be distributed orreleased.

ObjectivesObjectives

• Describe the major health effects ofselected TICs, TIMs, and otherimportant non-volatile chemicalagents that could be used byterrorists.

• Understand the behavioralresponses of people to masschemical exposures.

• Describe the major health effects ofselected TICs, TIMs, and otherimportant non-volatile chemicalagents that could be used byterrorists.

• Understand the behavioralresponses of people to masschemical exposures.

American College ofMedical Toxicology

American College ofMedical Toxicology

• Professional association ofphysicians with recognized expertiseand board certification in medicaltoxicology.

• Sub-specialty focused on thediagnosis, management andprevention of human poisoning andother adverse health effects due tomedications, occupational andenvironmental toxicants andbiological agents.

• Professional association ofphysicians with recognized expertiseand board certification in medicaltoxicology.

• Sub-specialty focused on thediagnosis, management andprevention of human poisoning andother adverse health effects due tomedications, occupational andenvironmental toxicants andbiological agents.

CourseCourse

• National: 5

• Regional: 5

• International 1

• Planned

7 Regional courses

• National: 5

• Regional: 5

• International 1

• Planned

7 Regional courses

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“Terrorists can make the'unlikely' happen."

“Terrorists can make the'unlikely' happen."

Ricin and al-Qa’ida?Ricin and al-Qa’ida?Jan 20, 2003Jan 20, 2003

October 22, 2003October 22, 2003 Even Defensive SurprisesEven Defensive Surprises

October 27, 2002October 27, 2002

October 29, 2002By Nick Paton WalshMoscow

The gas used in the Moscow theatresiege by the Russian military was mostlikely a rare form of nerve agentdeveloped by US forces in the 1970s,Western chemical warfare experts saidyesterday.

October 29, 2002By Nick Paton WalshMoscow

The gas used in the Moscow theatresiege by the Russian military was mostlikely a rare form of nerve agentdeveloped by US forces in the 1970s,Western chemical warfare experts saidyesterday.

Rescuers ‘probably usednerve gas’

Rescuers ‘probably usednerve gas’

Russian and UK ExpertsBelieve Moscow Gas Was BZ

Russian and UK ExpertsBelieve Moscow Gas Was BZ

The world wants to know why 117hostages died as a result of theoperation.

english.pravda.ru

The world wants to know why 117hostages died as a result of theoperation.

english.pravda.ru

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Doctors Try To SolveGas Mystery

Doctors Try To SolveGas Mystery

Monday, October 28, 2002Posted: 1:34 PM EST (1834 GMT)

Monday, October 28, 2002Posted: 1:34 PM EST (1834 GMT)

Official “Battlefield”Chemical Warfare Agents

Official “Battlefield”Chemical Warfare Agents

• Purpose Designed– Nerve (eg. Sarin, VX)– Blister (eg. Mustard)– 1° focus of chemical defense

programs in past• Dual Use Industrial Chemicals

– Blood (eg. CN)– Choking (eg. Phosgene)– Less emphasis on industrial

chemicals as a military threat

• Purpose Designed– Nerve (eg. Sarin, VX)– Blister (eg. Mustard)– 1° focus of chemical defense

programs in past• Dual Use Industrial Chemicals

– Blood (eg. CN)– Choking (eg. Phosgene)– Less emphasis on industrial

chemicals as a military threat

TICs and TIMsTICs and TIMs

• Toxic Industrial Chemicals (TICs)

Any chemical substance that canrender troops ineffective undernormal MOPP (mission orientedprotective posture) conditions.Primarily an inhalation hazard buttroops can receive a dosage throughingestion or absorption of the skin.

• Toxic Industrial Chemicals (TICs)

Any chemical substance that canrender troops ineffective undernormal MOPP (mission orientedprotective posture) conditions.Primarily an inhalation hazard buttroops can receive a dosage throughingestion or absorption of the skin.

TICs and TIMsTICs and TIMs TICs and TIMsTICs and TIMs

• Toxic Industrial Materials (TIMs)

Any substance that in a given quantity produces a toxic effect in exposed personnel through inhalation, ingestion, or absorption.

• Toxic Industrial Materials (TIMs)

Any substance that in a given quantity produces a toxic effect in exposed personnel through inhalation, ingestion, or absorption.

TICs and TIMsTICs and TIMs

International Task Force-40Industrial Chemical

Prioritization


Prioritization• Selected Acutely Toxic Airborne

Hazards

• Acrolein

• Ammonia

• Arsine

• Chlorine

• Cyanogen Chloride

• Selected Acutely Toxic AirborneHazards

• Acrolein

• Ammonia

• Arsine

• Chlorine

• Cyanogen Chloride


Prioritization


Prioritization• Phosgene

• Nitrogen Dioxide

• Sulfur dioxide

• Selected Acutely Toxic Ingestants

• Organophosphates

• Cyanides

• Arsenic compounds

• Phosgene

• Nitrogen Dioxide

• Sulfur dioxide

• Selected Acutely Toxic Ingestants

• Organophosphates

• Cyanides

• Arsenic compounds

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Other Chemical ConcernsOther Chemical Concerns

• Metals

• Pharmaceuticals

• Illicit / Substances of Abuse

• Toxic Waste

• Metals

• Pharmaceuticals

• Illicit / Substances of Abuse

• Toxic Waste

Toxic WarfareToxic Warfare

• Definition – the use of chemicals (orindustrial waste) to harm or alter thebehavior of an adversary

• Utilizes existing stored chemicals –exploiting weapons of opportunity

• Definition – the use of chemicals (orindustrial waste) to harm or alter thebehavior of an adversary

• Utilizes existing stored chemicals –exploiting weapons of opportunity

Toxic WarfareToxic Warfare

• Who’s at risk

– Military abroad

– Civilians in U.S.

• Wide availability of toxicmaterials throughout U.S.

• Proximity of industrialoperations to large urbancenters

• Who’s at risk

– Military abroad

– Civilians in U.S.

• Wide availability of toxicmaterials throughout U.S.

• Proximity of industrialoperations to large urbancenters

Goals of Toxic WarfareGoals of Toxic Warfare

• Health Effects– Incapacitating adversary vs. killing

adversary.• Damage / contamination of military

or civilian infrastructure.– Halt or delay military logistics– Disrupt functioning of urban

infrastructure

• Health Effects– Incapacitating adversary vs. killing

adversary.• Damage / contamination of military

or civilian infrastructure.– Halt or delay military logistics– Disrupt functioning of urban

infrastructure

Goals of Toxic WarfareGoals of Toxic Warfare

• Psychological effects resulting fromactual or threatened use of toxicsubstances - terrorizing.– Asymmetrical warfare– Create uncertainty, fear and panic– Uncertainties provide tactical

and/or psychological advantages

• Psychological effects resulting fromactual or threatened use of toxicsubstances - terrorizing.– Asymmetrical warfare– Create uncertainty, fear and panic– Uncertainties provide tactical

and/or psychological advantages

Why Use Industrial Chemicals AsWMDs?

Why Use Industrial Chemicals AsWMDs?

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Limitations with Purpose-Designed WMD Aum Shinrikyo -

Tokyo 1995 - Sarin

Limitations with Purpose-Designed WMD Aum Shinrikyo -

Tokyo 1995 - Sarin

• Spent ~$30 million on chemicalweapons research

• Employed many scientists

• Killed only 19

• Problems with

– Production

– Effective delivery system

• Spent ~$30 million on chemicalweapons research

• Employed many scientists

• Killed only 19

• Problems with

– Production

– Effective delivery system

Much More EffectiveBhopal - 1984

Much More EffectiveBhopal - 1984

• Methyl isocyanate

• > 2500 deaths

• 60,000 injuries

• Methyl isocyanate

• > 2500 deaths

• 60,000 injuries

TICs/TIMs vs. CW AgentsTICs/TIMs vs. CW Agents• TICs/TIMs• Greater available volume offsets

lower toxicity• Accessible• Much less secure• Inexpensive• May be legally available• Difficult detection• Effective without lethality

• TICs/TIMs• Greater available volume offsets

lower toxicity• Accessible• Much less secure• Inexpensive• May be legally available• Difficult detection• Effective without lethality

TICs/TIMs vs. CW AgentsTICs/TIMs vs. CW Agents

• Acute and/or chronic effects• Purpose Designed WMD• Higher toxicity• Lack of accessibility• Tight security• Known threat• Designed to create casualties• Primarily acute effects

• Acute and/or chronic effects• Purpose Designed WMD• Higher toxicity• Lack of accessibility• Tight security• Known threat• Designed to create casualties• Primarily acute effects

Why Should We WorryWhy Should We Worry

• ~ 850,000 U.S. businesses use,produce, or store TICs.

• EPA report – 123 chemical plantsacross the U.S. have enough toxicchemicals to kill/injure 1 millionpeople in terrorist attack.

• ~ 850,000 U.S. businesses use,produce, or store TICs.

• EPA report – 123 chemical plantsacross the U.S. have enough toxicchemicals to kill/injure 1 millionpeople in terrorist attack.

Why Should We WorryWhy Should We Worry

• 750 other plants have enoughchemicals to kill/injure at least100,000 people in an attack.

• U.S. Army study - terrorist attack onchemical plant in densely populatedarea could result in 2.4 millionfatalities or injuries.

• 750 other plants have enoughchemicals to kill/injure at least100,000 people in an attack.

• U.S. Army study - terrorist attack onchemical plant in densely populatedarea could result in 2.4 millionfatalities or injuries.

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Deadly PossibilitiesDeadly Possibilities• California chemical plant routinely

loads chlorine into 90-ton railroadcars - rupture could poison > 4million people in surroundingcounties.

• Philadelphia refinery stores 400,000pounds of hydrogen fluoride - couldasphyxiate nearly 4 million nearbyresidents.

• California chemical plant routinelyloads chlorine into 90-ton railroadcars - rupture could poison > 4million people in surroundingcounties.

• Philadelphia refinery stores 400,000pounds of hydrogen fluoride - couldasphyxiate nearly 4 million nearbyresidents.

Deadly PossibilitiesDeadly Possibilities

• West Virginia plant (Union Carbide)stores as much as 200,000 pounds ofmethyl isocyanate - could emit atoxic fog over 60,000 people.

• Tennessee chemical plants stores500,000 pounds of sulfur dioxide -release - as many as 60,000 peopleliving within reach of the ensuingvapor cloud are at risk of death orserious injury.

• West Virginia plant (Union Carbide)stores as much as 200,000 pounds ofmethyl isocyanate - could emit atoxic fog over 60,000 people.

• Tennessee chemical plants stores500,000 pounds of sulfur dioxide -release - as many as 60,000 peopleliving within reach of the ensuingvapor cloud are at risk of death orserious injury.

Sources of TICs and TIMs (1)Sources of TICs and TIMs (1)

AirportsAirports College LabsCollege Labs

Farm and Garden SupplyFarm and Garden SupplyToxic Waste

DumpsToxic Waste

Dumps

GlassPlantsGlassPlants

Sources of TICs and TIMs (2)Sources of TICs and TIMs (2)

TransformersTransformers

Propane TanksPropane TanksPhotographicSuppliesPhotographicSupplies

RailroadsRailroads

MedicalFacilitiesMedical

Facilities

Another SourceAnother Source

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# of Terrorist Cases InvolvingChemical Substances

1975- August 2000

# of Terrorist Cases InvolvingChemical Substances

1975- August 2000

• Domestic: 46 (22.2%)

• International: 161 (77.8%)

• Total: 207

• Domestic: 46 (22.2%)

• International: 161 (77.8%)

• Total: 207

Monterey Institute Database, 2000Monterey Institute Database, 2000

Types of Terrorists Activities(Chemical n=207 and Biological n=135)Types of Terrorists Activities

(Chemical n=207 and Biological n=135)

Concern:• Hoax/prank/threat 120 (35%)• Plot only 28 (8%)Serious Concern:• Attempted acquisition 9 (3%)• Possession 48 (14%)• Threat with Possession 11 (3%)Grave ConcernUse of agent 126 (37%)

Concern:• Hoax/prank/threat 120 (35%)• Plot only 28 (8%)Serious Concern:• Attempted acquisition 9 (3%)• Possession 48 (14%)• Threat with Possession 11 (3%)Grave ConcernUse of agent 126 (37%)


Methods Employed byTerrorists for Delivery of

Chemical (N=126)


Chemical (N=126)• Casual/direct contact 33 (30%)• Aerosol/spray 21 (19%)• Food/drink 13 (12%)• Unknown 12 (11%)• Product tampering 10 (9%)• Explosive 6 (5%)• Water supply 5 (4%)

• Casual/direct contact 33 (30%)• Aerosol/spray 21 (19%)• Food/drink 13 (12%)• Unknown 12 (11%)• Product tampering 10 (9%)• Explosive 6 (5%)• Water supply 5 (4%)



Chemical (N=126)


Chemical (N=126)

• Jug/jar/canister 1 (1%)• Mail/letter 4 (3%)• Reaction device 3 (2%)• Injection/projectile 1 (1%)

• Jug/jar/canister 1 (1%)• Mail/letter 4 (3%)• Reaction device 3 (2%)• Injection/projectile 1 (1%)


Chemical Agents Used2000-2002

Chemical Agents Used2000-2002

000011RodenticidesRodenticides

001111CyanideCyanide

110000PesticidePesticide

001100Poison gasPoison gas

000011ArsenicArsenic

114488Acid / AlkaliAcid / Alkali

200220022001200120002000AgentAgent


Challenges of ChemicalAgent Identification


• Symptoms of exposure to chemicalagents may be similar to commondisease (gastroenteritis).

• Immediate symptoms might be mild ornonexistent despite risk of long-termeffects.

• Symptoms of exposure to chemicalagents may be similar to commondisease (gastroenteritis).

• Immediate symptoms might be mild ornonexistent despite risk of long-termeffects.

MMWR 10/3/03MMWR 10/3/03

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• Reports of contaminated food/watermight result in staggered reports overlong periods / different locations.

• Mixed clinical presentation may resultfrom exposure to 2 or more agents.

• Health care providers may be lessfamiliar with certain chemical inducedpresentations.

• Reports of contaminated food/watermight result in staggered reports overlong periods / different locations.

• Mixed clinical presentation may resultfrom exposure to 2 or more agents.

• Health care providers may be lessfamiliar with certain chemical inducedpresentations.

MMWR 10/3/03MMWR 10/3/03

Epidemiological CluesSuggesting Covert Release of

Chemical Agent


Chemical Agent

• Unusual increase in # of patientsseeking care for potential chemicalrelease related illness.

• Unexplained deaths among young orhealthy people or plants and animals.

• Unexplained odors by patients.

• Unusual increase in # of patientsseeking care for potential chemicalrelease related illness.

• Unexplained deaths among young orhealthy people or plants and animals.

• Unexplained odors by patients.

MMWR 10/3/03 MMWR 10/3/03


Chemical Agent


Chemical Agent

• Cluster of illness in patients withcommon characteristics such assimilar drinking water.

• Rapid onset of symptoms afterexposure to potentially contaminatedmedium.

• Presence of a particular clinicalpattern or toxidrome.

• Cluster of illness in patients withcommon characteristics such assimilar drinking water.

• Rapid onset of symptoms afterexposure to potentially contaminatedmedium.

• Presence of a particular clinicalpattern or toxidrome.

MMWR 10/3/03 MMWR 10/3/03

Selected Clinical Syndromes(Toxidromes) and Potential

Chemical Etiologies

Selected Clinical Syndromes(Toxidromes) and Potential

Chemical Etiologies

Paraquat / diquat;caustics, Hg

Paraquat / diquat;caustics, Hg

Lip / mouth / pharyngealulcerations; burningpain

Lip / mouth / pharyngealulcerations; burningpain

Mouth pain /ulcerations

Mouth pain /ulcerations

Hg, As, Thallium,Lead,

Hg, As, Thallium,Lead,

Muscle weakness,sensory loss

Muscle weakness,sensory loss

Peripheralneuropathy

Peripheralneuropathy

CN, SMFA, CO, AzideCN, SMFA, CO, AzideN/V, headache, AMS,shock, seizures, dec pHN/V, headache, AMS,shock, seizures, dec pH

Cellular hypoxiaCellular hypoxia

OP insecticides,nicotineOP insecticides,nicotine

SLUDGE symptoms,

Fasciculations,weakness

SLUDGE symptoms,

Fasciculations,weakness

Cholinergic crisisCholinergic crisis

Arsenic, Ricin,Colchicine

Arsenic, Ricin,Colchicine

Abdominal pain, emesisprofuse diarrhea, shock

Abdominal pain, emesisprofuse diarrhea, shock

Severegastroenteritis

Severegastroenteritis

PotentialChemicalEtiology

PotentialChemicalEtiology

Clinical SyndromeClinical SyndromeCategoryCategory

MMWR 10/3/03MMWR 10/3/03

A CaseA Case

• 49 year old man suddenly developsleg pain while walking

• 15-24 hours – fever, nausea, vomiting

• 36 hours – admitted to hospital withfever, tachycardia, and lymph nodeswelling

• 49 year old man suddenly developsleg pain while walking

• 15-24 hours – fever, nausea, vomiting

• 36 hours – admitted to hospital withfever, tachycardia, and lymph nodeswelling

A CaseA Case

• 48 hours – hypotension / shock

• 72 hours – anuria, vomited blood,heart block

• 84 hours – death

• Presumed cause of death – SepticShock

• 48 hours – hypotension / shock

• 72 hours – anuria, vomited blood,heart block

• 84 hours – death

• Presumed cause of death – SepticShock

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ReleaseCatch

GasCylinder

PoisonPellet

Trigger Spring Piercer Barrel

Castor Bean Plant(Ricinus communis)Castor Bean Plant

(Ricinus communis)

Cultivated commerciallyas a source of castor oilCultivated commerciallyas a source of castor oil Castor BeansCastor Beans

Ricin- dichainpolypeptide

Ricin- dichainpolypeptide

Ricin – Basic FactsRicin – Basic Facts

• Cellular toxin – blocks proteinsynthesis via modification ofribosomal 28s subunit

• Forms – mist, powder, pellet• Clinical presentation varies with

dose and route of exposure– Parenteral: local pain, systemic

toxicity, multisystem failure– lethal dose - 500 µg (head of a pin)

• Cellular toxin – blocks proteinsynthesis via modification ofribosomal 28s subunit

• Forms – mist, powder, pellet• Clinical presentation varies with

dose and route of exposure– Parenteral: local pain, systemic

toxicity, multisystem failure– lethal dose - 500 µg (head of a pin)

Ricin – Basic FactsRicin – Basic Facts

– Inhalation: respiratory distress,necrotizing pneumonitis

– Human reports: allergic syndromereported in exposed workers

– Oral: GI distress, internal bleeding,visceral necrosis

– Inhalation: respiratory distress,necrotizing pneumonitis

– Human reports: allergic syndromereported in exposed workers

– Oral: GI distress, internal bleeding,visceral necrosis

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Toxic Gasesin Your Community

Toxic Gasesin Your Community

Industrial Chemical EventIndustrial Chemical Event

Chemical Accidents in U.S.Industry RMP for 1994-1999

Chemical Accidents in U.S.Industry RMP for 1994-1999

#1 Anhydrous Ammonia 656#2 Chlorine 518#3 Hydrogen Fluoride 101#4 Flammable Mixture 99#5 Chlorine Dioxide 55#6 Propane 54#7 Sulfur Dioxide 48#8 Ammonia (>20%) 43#9 Hydrogen Chloride 32#19 Phosgene 12

#1 Anhydrous Ammonia 656#2 Chlorine 518#3 Hydrogen Fluoride 101#4 Flammable Mixture 99#5 Chlorine Dioxide 55#6 Propane 54#7 Sulfur Dioxide 48#8 Ammonia (>20%) 43#9 Hydrogen Chloride 32#19 Phosgene 12

Clinical ManifestationsBased on Characteristics

of Agent


of Agent

• High water solubility

• Rapid onset of symptoms

• Good warning properties

• Upper airway irritation and injury

• Poor water solubility

• High water solubility

• Rapid onset of symptoms

• Good warning properties

• Upper airway irritation and injury

• Poor water solubility

Ammonia > Chlorine > Phosgene


of Agent


of Agent

• Delayed onset of symptoms

• Poor warning properties

• Lower airway and lung injury

• Delayed onset of symptoms

• Poor warning properties

• Lower airway and lung injury

Ammonia > Chlorine > Phosgene

ChlorinePhysical Properties

ChlorinePhysical Properties

• Intermediate water solubility

• Low odor threshold

• Green-yellow, pungent gas

• Boiling point –31 oF

• 2.5 x heavier than air

• Reacts explosively with manycompounds

• Intermediate water solubility

• Low odor threshold

• Green-yellow, pungent gas

• Boiling point –31 oF

• 2.5 x heavier than air

• Reacts explosively with manycompounds

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ChlorineClinical Manifestations

ChlorineClinical Manifestations

• Intermediate water-solubility• Low concentration: irritant to eyes,

nose, throat, upper respiratory tract• High concentration or prolonged

exposure: severe lower airway andlung damage– Chemical pneumonitis– Pulmonary edema– Pulmonary function abnormalities– Chronic airway disease

• Intermediate water-solubility• Low concentration: irritant to eyes,

nose, throat, upper respiratory tract• High concentration or prolonged

exposure: severe lower airway andlung damage– Chemical pneumonitis– Pulmonary edema– Pulmonary function abnormalities– Chronic airway disease

ChlorineInhalational Injury

ChlorineInhalational Injury

ChlorineWorld War IChlorine

World War I

Battle of Loos, September 1915Battle of Loos, September 1915

Chlorine GasRespiratorsChlorine GasRespirators

ChlorineChlorine• Used in

– Manufacturing of nonagricultural chemicals– Pulp and paper industry– Commercial and household

bleaching agents– Water purification and waste

treatment systems• 1998 US production exceeded 14

million tons– Shipped as liquefied compressed

gas

• Used in– Manufacturing of nonagricultural chemicals– Pulp and paper industry– Commercial and household

bleaching agents– Water purification and waste

treatment systems• 1998 US production exceeded 14

million tons– Shipped as liquefied compressed

gas

Chlorine Community Threat

Assessment

Chlorine Community Threat

Assessment

Fixed FacilityFixed Facility

In TransitIn Transit

Chlorine GasAlberton, Montana

Chlorine GasAlberton, Montana

• 72-car train derailment

• 4 tanker cars contained chlorine gas

• Carrying capacity of 90 tons

• 265,000 pounds toxic chemicalsreleased

• 1 dead, 352 hospitalized

• 72-car train derailment

• 4 tanker cars contained chlorine gas

• Carrying capacity of 90 tons

• 265,000 pounds toxic chemicalsreleased

• 1 dead, 352 hospitalized

“Toxic trains may be rumbling through your own town”

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Water as an Opportunity forChemical Terrorism

Water as an Opportunity forChemical Terrorism

Chemical Water TerrorismHistory


• 1986: NYC; plutonium in drinkingwater

• 1989: Romania; water supplypoisoned with an organophosphate

• 1996: China; students poisoned afterwell serving school was intentionallycontaminated

• 1998: Kosovo; wells poisoned

• 1986: NYC; plutonium in drinkingwater

• 1989: Romania; water supplypoisoned with an organophosphate

• 1996: China; students poisoned afterwell serving school was intentionallycontaminated

• 1998: Kosovo; wells poisoned



• 2000: NYC; bottled watercontaminated

• 2002: Rome; threat to contaminatewater supplies to U.S. Embassy withcyanide

• 2000: NYC; bottled watercontaminated

• 2002: Rome; threat to contaminatewater supplies to U.S. Embassy withcyanide

Potential Hostile Actions toDrinking Water

Potential Hostile Actions toDrinking Water

• Biological agents

• Chemical agents

– Industrial, natural toxins

• Radiological agents

• Damage & destruction of physicalinfrastructure

• Disruption to computer systems

• Biological agents

• Chemical agents

– Industrial, natural toxins

• Radiological agents

• Damage & destruction of physicalinfrastructure

• Disruption to computer systems

Chemical Water TerrorismChemical Water Terrorism

• Acts that deliberately interrupt:

– SUPPLY of water

• Physical destruction

• Water pressure in a system

• Computer/data systems

– QUALITY of water

• Direct injection ofcontaminants/poisons

• Acts that deliberately interrupt:

– SUPPLY of water

• Physical destruction

• Water pressure in a system

• Computer/data systems

– QUALITY of water

• Direct injection ofcontaminants/poisons

Threats to Water SystemInfrastructure

Threats to Water SystemInfrastructure

Surface Source(river, lake, dam)

Local WaterSystem

TreatmentTreatment

StorageStorage

WellWell

DistributionSystem

TowerHomes

Battlefield WaterSupplies

Fire hydrants

Toxic WasteDumps

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Drinking Water –Ideal ContaminantDrinking Water –

Ideal Contaminant

• Readily available

• Odorless

• Tasteless

• Colorless

• Water soluble

• Stable in water

• Unexpected

• Readily available

• Odorless

• Tasteless

• Colorless

• Water soluble

• Stable in water

• Unexpected

Drinking Water –Ideal ContaminantDrinking Water –

Ideal Contaminant

• Low LD50

• Resists water treatment

• Difficult to detect in water

• Difficult to decontaminate

• Pipes, reservoirs, etc.

• Illness: delayed onset and difficult todiagnose

• Low LD50

• Resists water treatment

• Difficult to detect in water

• Difficult to decontaminate

• Pipes, reservoirs, etc.

• Illness: delayed onset and difficult todiagnose

Relative Water ToxicityRelative Water Toxicity

11Arsenite, arsenateArsenite, arsenate11Na FluoroacetateNa Fluoroacetate55AmitonAmiton99CyanideCyanide2020NicotineNicotine100100SarinSarin300300VXVX10,00010,000Botulinum ToxinBotulinum ToxinRRCompoundCompound R =

Solubility/Lethal Dose(mg) x 1000

R =Solubility/Lethal Dose(mg) x 1000

Clark R: J Contingencies Crisis Management 2000Clark R: J Contingencies Crisis Management 2000

Water System VulnerabilitiesWater System Vulnerabilities

• Essential for Health

• Vulnerable characteristics in thewater system

– Spatially diverse, susceptible tointrusion

– Numerous components to thesystem, innumerable attack sites

• Essential for Health

• Vulnerable characteristics in thewater system

– Spatially diverse, susceptible tointrusion

– Numerous components to thesystem, innumerable attack sites

Water System Vulnerabilities(continued)

Water System Vulnerabilities(continued)

– Distribution system closest toconsumers (less dilution andreside in system for shorter times)

– Bottled water, Sewage facilities

• Dilutional effects

– Large quantity to have major effect

• Difficult to identify/track chemical

– Distribution system closest toconsumers (less dilution andreside in system for shorter times)

– Bottled water, Sewage facilities

• Dilutional effects

– Large quantity to have major effect

• Difficult to identify/track chemical

Rapid Field Testing KitsRapid Field Testing Kits

• DeltaTOX

• Eclox Rapid Water Test

• IQ-Tox Test

• MicroTOX

• DeltaTOX

• Eclox Rapid Water Test

• IQ-Tox Test

• MicroTOX

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Water Terrorism:Major Consequences

Water Terrorism:Major Consequences

• Widespread fear and panic

• Undermine public confidence ingovernment’s ability to protectcitizens

• Social and economic disruption

• Loss of drinking water

• Widespread fear and panic

• Undermine public confidence ingovernment’s ability to protectcitizens

• Social and economic disruption

• Loss of drinking water

Observed Behaviors DuringMass Chemical Exposures

Are All of These PatientsPoisoned?

Observed Behaviors DuringMass Chemical Exposures

Are All of These PatientsPoisoned?

Chemical Agents ofOpportunityChemical Agents ofOpportunity

Does “hysteria” explain a group’snonspecific symptoms with no

apparent exposure?

Does “hysteria” explain a group’snonspecific symptoms with no

apparent exposure?

What Is It Called?What Is It Called?

• Mass Hysteria• Epidemic Hysteria• Mass Psychogenic Illness• Epidemic Psychogenic Illness• Psychological Sequelae• Psychic Possession• Crowd Poison• Psychosocial Casualties

• Mass Hysteria• Epidemic Hysteria• Mass Psychogenic Illness• Epidemic Psychogenic Illness• Psychological Sequelae• Psychic Possession• Crowd Poison• Psychosocial Casualties

What Is It Called?What Is It Called?• Epidemic Transient Situational

Disturbance• Mass Sociogenic Illness (by proxy)• Environmental Somatization

Syndrome• Traumatic Stress Response

• Epidemic Transient SituationalDisturbance

• Mass Sociogenic Illness (by proxy)• Environmental Somatization

Syndrome• Traumatic Stress Response

76 terms found inliterature to identify“mass hysteria”Bartholomew 1990

76 terms found inliterature to identify“mass hysteria”Bartholomew 1990

Features Suggestive of“Mass Psychogenic Illness”

Features Suggestive of“Mass Psychogenic Illness”

• Sudden onset of symptoms afterleaving alleged source of exposure

• Significant symptoms not c/wexpected toxic effects

• Diversity of symptoms w/o physicalsigns or abnormal labs

• Symptoms develop after learning ofthe suspected exposure

• Recurrences in those congregated• Benign morbidity with no sequelae

• Sudden onset of symptoms afterleaving alleged source of exposure

• Significant symptoms not c/wexpected toxic effects

• Diversity of symptoms w/o physicalsigns or abnormal labs

• Symptoms develop after learning ofthe suspected exposure

• Recurrences in those congregated• Benign morbidity with no sequelae

Boxer JOM 1985Boxer JOM 1985

15

Most Common Symptoms of“Mass Psychogenic Illness”Most Common Symptoms of“Mass Psychogenic Illness”

• Headache• Dizziness/lightheadedness• Nausea• Dry mouth• Eye/nose/throat irritation• Drowsiness• Numbness and tingling• Chest tightness• Weakness

• Headache• Dizziness/lightheadedness• Nausea• Dry mouth• Eye/nose/throat irritation• Drowsiness• Numbness and tingling• Chest tightness• Weakness

Boxer JOM 1985Boxer JOM 1985

Beware of toxicity mimicking“psychogenic illness”

Beware of toxicity mimicking“psychogenic illness”

Is It Psychologic OrPoisoning?


Nerve Agent Poisoning:• Chest tightness• Dyspnea• Tachycardia• Nausea/Vomiting• Abdominal cramps• Involuntary urination• Fasciculations• Headache• Coma• Diaphoresis

Nerve Agent Poisoning:• Chest tightness• Dyspnea• Tachycardia• Nausea/Vomiting• Abdominal cramps• Involuntary urination• Fasciculations• Headache• Coma• Diaphoresis



Psychological:• Chest tightness• Dyspnea• Tachycardia• Nausea/Vomiting• Abdominal cramps• Involuntary urination• Tremor• Headache• Syncope• Diaphoresis

Psychological:• Chest tightness• Dyspnea• Tachycardia• Nausea/Vomiting• Abdominal cramps• Involuntary urination• Tremor• Headache• Syncope• Diaphoresis

Is It Contagious?Is It Contagious?

• Crowd Poison• “Groups without nerve agent

exposure complained of symptomsexperienced by those who had beenexposed.”

Fullerton Mil Med 1990• Symptoms spread

– proximity of affected/unaffectedpersons

– Reassembly of the group– “line of sight transmission”

Jones NEJM 2000

• Crowd Poison• “Groups without nerve agent

exposure complained of symptomsexperienced by those who had beenexposed.”

Fullerton Mil Med 1990• Symptoms spread

– proximity of affected/unaffectedpersons

– Reassembly of the group– “line of sight transmission”

Jones NEJM 2000

Proposed SolutionsProposed Solutions

• Expect the problem – Plan for it• Don’t ignore these patients

– In planning– In taking them seriously

• Teach emergency responders somebasic toxicology principles– e.g., Dose-Response

• Expect the problem – Plan for it• Don’t ignore these patients

– In planning– In taking them seriously

• Teach emergency responders somebasic toxicology principles– e.g., Dose-Response

16

Proposed SolutionsProposed Solutions

• Look for objective signs of toxicity• Create a “holding environment”

– Location away from high-tempotriage activities

– Symptoms monitored andre-evaluation

• Look for objective signs of toxicity• Create a “holding environment”

– Location away from high-tempotriage activities

– Symptoms monitored andre-evaluation

ConclusionsConclusions• Toxic warfare- necessary to look

beyond conventional chemicalweapons.

• “Chemical Agents of Opportunity”are readily available and presentlikely threats of chemical terrorism inour communities and nation.

• Understanding behaviors duringmass chemical exposures/disastersis important for appropriateevaluation and management ofvictims and health care workers.

• Toxic warfare- necessary to lookbeyond conventional chemicalweapons.

• “Chemical Agents of Opportunity”are readily available and presentlikely threats of chemical terrorism inour communities and nation.

• Understanding behaviors duringmass chemical exposures/disastersis important for appropriateevaluation and management ofvictims and health care workers.

AcknowledgementsAcknowledgements

• Paul Wax, MD, FACMT

• Lewis Nelson, MD, FACMT

• Mark Kirk, MD, FACMT

• Thomas Martin, MD, FACMT

• Curtis Snook, MD, FACMT

• Mary Wittler, MD

• Paul Wax, MD, FACMT

• Lewis Nelson, MD, FACMT

• Mark Kirk, MD, FACMT

• Thomas Martin, MD, FACMT

• Curtis Snook, MD, FACMT

• Mary Wittler, MD

Upcoming ProgramsUpcoming Programs

The Behavioral Health Responseto Disasters

Tuesday, August 24, 2004


Emerging Trends: STD Treatment andBody Piercing

Tuesday, September 14, 2004


The Behavioral Health Responseto Disasters

Tuesday, August 24, 2004


Emerging Trends: STD Treatment andBody Piercing

Tuesday, September 14, 2004


Documents

Chemical Agents of Facultyadph.org/ALPHTN/assets/356chemicalhandouts.pdf · biological agents. • Professional association of physicians with recognized expertise and board certification