Are health systems prepared for chemical warfare in Ukraine?

As the war in Ukraine continues, the question is increasingly how far the Russian military will go to prevail against Ukraine. The last concern? Fear that Russia will start using Chemical Weapons.

Although it is uncertain at this time whether Russia will actually launch such an attack, one thing is clear: in a large-scale chemical attack in the current Russian-Ukrainian conflict, the prospect of a meaningful health response is bleak. .

cause for concern

In 1986, the Cooperative Threat Reduction (CTR) program was launched. The program, better known as the Nunn-Lugar Act, was created to secure and dismantle weapons of mass destruction and their associated infrastructure in the former Soviet Union, including Ukraine. The operation of the CTR program has been openly discussed since its inception, and the program has operated in a number of Ukrainian laboratories for biosafety and training purposes.

Just recently, Russia filed a complaint with the UN Security Council to respond to its accusation that the United States and Ukraine are instead using the CTR program to develop chemical and biological weapons with the intention of use them in the current Russian-Ukrainian conflict. According to dispatches from the White House response, Russia may have claimed “lay the foundation“for its own use of such weapons against Ukraine.

How could such an attack work? Chemical and biological agents can be prepared in secret, are easily concealed, and can be easily introduced into the air, water or food supply. Chemical agents can be broadly categorized as blisters/blisters such as mustard, blood agents such as hydrogen cyanide, choking/pulmonary agents such as chlorine gas, incapacitating agents such as opioids and nerve agents such as sarin or Russian-made Novichok. In the modern era, the development of chemical weapons originated in the 1930s with the development of nerve agents – organophosphate cholinesterase inhibitors, each having a particular potency.

Nerve agents are colorless and odorless, and the classic four include sarin, soman, tabun, and US-produced VX. V agents were at one time considered the most toxic agents ever produced and are ten times more toxic than sarin. Large scale production of VX took place in America in 1961 with the production of tons of the chemical agent. VX can kill a person quickly after exposure to an infinitesimal amount, especially the amount needed to cover just two columns on the Lincoln Memorial on the back of a penny.

If a person is exposed to a nerve agent, a constellation of symptoms occurs. Nerve agents block the action of acetylcholinesterase, which leads to the accumulation of the neurotransmitter acetylcholine. High levels of acetylcholine in the synaptic cleft cause overstimulation of cholinergic receptors. Symptoms related to excessive acetylcholine buildup are divided into three groups: muscarinic, nicotinic, and central. Overstimulation of muscarinic cholinergic receptors causes pupillary constriction, glandular hypersecretion, urination, defecation, sweating and vomiting. The nicotine symptoms are weakness and eventually paralysis. Central nervous system poisoning will manifest as irritability, delirium, fatigue, lethargy, convulsions, coma and death from respiratory depression. Obviously, these symptoms should not be taken lightly.

Impact on health and health care

The use of chemical weapons in war poses a particular problem for health care. Such weapons can create a complex event involving a large number of casualties when medical personnel and health facilities may themselves be in the conflict zone. Both chemical and biological attacks require intense and complex treatment, and in both types of attacks the medical staff themselves may be at risk of exposure and therefore decontamination may be required before anything begins. supportive treatment. Emergency and medical care providers should also have access to appropriate respiratory protection and hazmat/chemical resistant suits, and in the event of a widespread attack, in an ever-deteriorating war zone like Ukraine, such processing capacity would be very limited.

It wouldn’t be the first time Russia has launched such an attack – the country has shown a willingness to use chemical agents in the past. In 2002, Chechen rebels took over a Moscow theater and held 700 hostages, threatening to execute them. Russian authorities stormed the theater after using incapacitating gas that may have been a mixture of remifentanil/halothane or extra strength carfentanil in aerosol form. Carfentanil is a synthetic opioid that is about 10,000 times more potent than morphine – it is intended for use as an anesthetic for large animals. The consequences of an opioid overdose are well known. In many cases, respiratory failure resulting in death is the accidental consequence. In the Moscow theater raid, opioids were specifically weaponized and death or injury was the specific intent. Immediately after the Russian raid, at least 33 Chechens and 129 hostages died, the vast majority of them from gas exposure and inadequate medical care. Russian authorities have refused to release specific information about the nature of the gas exposure, significantly hampering the health emergency response.

Russia has also apparently used Novichok, the chemical nerve agent developed by the former Soviet Union and Russia. Novichok in some variants can be even more potent than VX – possibly eight times as potent. Novichok came to public attention as an agent used in attempts to kill opponents of the Russian government. The most recent event was the 2020 assassination attempt on Alexei Navalny. The use of Novichok as a poisoning agent was disputed, but immediate and subsequent treatment was tailored to treat nerve agent exposure and included high doses of atropine. Navalny survived, but treating a single individual required a labor-intensive, organized and sophisticated healthcare response. Widespread use of Novichok – or any other chemical agent in a war zone – threatens to be almost universally lethal, potentially killing exposed members of the public, Ukrainian military and first responders.

So, based on past history, there is a pattern and willingness on Russia’s part to deploy chemical and even biological agents while projecting or distracting. Indeed, the Russian government’s claim to biological weapons stored in Ukraine served to further galvanize the polarization of the war effort. Despite this, at the UN Security Council meeting on March 12, the High Representative for Disarmament Affairs, Izumi Nakamitsu, indicated that the UN is “unaware of biological weapons programs. “And to those who note that there are biological research facilities in Ukraine, it should be clear: biodefense, including the production of medical countermeasures (diagnostics, therapeutics, personal protective equipment) is an essential component of biohazard management and – preparedness Medical countermeasures should be prioritized in shipments to Ukraine, in addition to standard resources We would do well to remember that health care response – and survival – will depend on it.

Gavin Harris, MD, is an assistant professor of infectious diseases and critical care at Emory University School of Medicine in Atlanta. His clinical expertise and research interests include disaster preparedness and biosecurity, medical education and care of critically ill patients, and academic work in military history and the history of medicine. Joel Zivot, MD, is an Associate Professor of Anesthesiology/Critical Care at Emory University School of Medicine. His clinical expertise and research interests include the care of critically ill patients in the operating room and intensive care, education and scholarly work in bioethics, anthropology of conflict resolution, law, politics and a variety of topics related to the monitoring and practice of anaesthesiology/critical care. .