By Mr. Frank Rando, CBRNE – Protective & Biomedical Countermeasures SME, University of Arizona & Ms. Dee Ruelas, Clinical Specialist, U.S. Customs and Border Protection, USA.
Amidst the backdrop of the armed conflict between Russia and Ukraine, looms the constant threat of non – conventional warfare utilizing CBRN agents, along with the inherent dangers of a radiological release from existing nuclear power facilities, including the remnants of the damaged Chernobyl Reactor #4.
Superimposed on this scenario, exists the possibility of biocontainment failures or other calamities associated with the seizure or destruction of biowarfare and biotechnological laboratories in the Ukraine.
Currently, the international community faces the implications and consequences of escalating aggression, violence and atrocities condoned and perpetrated by a nation – state actor which is a nuclear- capable superpower. In addition, we continue to face the challenges of mitigation and response to a pandemic emergency that has killed millions and overwhelmed global public health and health care delivery systems.
Emerging infectious diseases seem to be nature’s perfect enemies facing humankind and purposely cultivating, engineering, and weaponizing microorganisms, old and new, to serve as weapons of war are a burgeoning threat to human, animal and plant life and health. Furthermore the use of CBRN materials in both domestic and international acts of terrorism as well as accidental releases of hazardous materials cannot be discounted.
History is replete with graphic examples of the health and medical effects of CBRN agents and hazardous materials, which also serve well as lessons learned.
We only need to revisit World War I, the atomic bombings of Hiroshima and Nagasaki, the horrific scenes of chemical warfare bestowed upon the indigenous populations of Iraq, Syria by the tyrannical regimes of Saddham Hussein and Assad, and some of the acts of terrorism and industrial accidents and technological disasters to see the devastating health effects of toxic, microbial and radiological – nuclear agents.
For example, the Iraq- Iran War of the 1980s Iranian combatants and civilians were attacked by Iraqi forces with mustard (sulfur mustard – HD) and neurotoxic chemical weapons (, ie the “nerve agents “), specifically tabun and sarin, which are “G- series “nerve agents. While, sulfur mustard (a vesicant or “blister agent “) has noted and dramatic effects on the integumentary system (skin), its vapor and respirable aerosols produce profound respiratory tract damage, including extensive airway necrosis , peribronchial fibrosis- a thickening in the tissues surrounding the bronchi , pseudo- membrane formation causing airway obstruction, pulmonary carcinogenesis and respiratory failure .
Sulfur and nitrogen mustards are also alkylating agents which can act similar to cancer chemotherapy drugs and mimic the effects of ionizing radiation (radiomimetic compound). This occurs as an effect on the DNA of cells, especially the rapidly dividing cells of the hematopoietic (blood forming) system in the bone marrow, fetal cells, reproductive cells, dermal cells and cells of the gastrointestinal tract.
Cytokine agents, such as Colony Stimulating Factor (CSF) that can stimulate the bone marrow would be essential in victims suffering from sulfur mustard toxicity. In addition, decontamination, chemical burn treatments, antiinfectives, antibiotics bronchodilators, fluid replacement therapy and vasopressors to treat shock would all be in the therapeutic armamentarium.
Mechanical ventilators and oxygen would be critical to provide respiratory support. As in radiation casualties, capabilities for bone marrow transplantation may be lifesaving.
Iranian medical and scientific teams have examined and performed studies of mustard agent exposed survivors and have discovered cascading biochemical perturbations and physiological abnormalities , including hyper inflammatory responses involving cytokines such as tumor necrosis factor (TNF – alpha ) , abnormal populations of natural killer cells and other immune cells , imbalances jn the protein – destroying enzymes called proteases , and a shortening of the telomeres on chromosomes , which denotes premature senescence (aging) of cells .
Much of the damage exacted by mustard agents is caused by free radical pathology and depletion of glutathione. Thus, N – acetylcysteine (NAC) has been shown experimentally and clinically to benefit mustard agent victims. Free radical scavenging antioxidant therapies would be helpful in offsetting oxidative stress and damage to cell membranes and DNA. CBRN agents and weapons, by their design and characteristics, are “weapons of mass effect “and “weapons of mass casualties “(WMEs / WMCs) and among their attributes are the causation of mass illness, injury and death among combatants and civilian populations. As such, the medical, healthcare and public health planning, preparedness and operational response to CBRN and hazardous materials events must engage the research and development and deployment of biomedical countermeasures.
Biomedical countermeasures include preventive or prophylactic, therapeutic and diagnostic pharmaceuticals, devices, equipment and operational platforms that can be deployed during or in the aftermath of a CBRN or related event, such as a radiological release, mass chemical exposure or a pandemic.
The development of new products to enhance or improve decontamination, and the actual phases of decontamination, such as gross and skin decontamination, are both protective and therapeutic as they serve to prevent cross contamination and prevent further exposures to and absorption of CBRN agents via routes of exposure such as inhalation and dermal or mucous membrane surfaces.
The following provides a brief synopsis of the types of biomedical and protective countermeasures that are available or under research and development at various military, governmental and academic research establishments.
Chemical – Antidotes, protective creams, antioxidants, newer decontamination agents, rapid assays, exposure biomarkers, PPE
Biological – Antimicrobials, antivirals, vaccines, antifungal compounds, antitoxins, immune boosters, rapid assays, advanced diagnostic platforms, immune modulators, pheresis for inflammatory cytokines in sepsis, nanotechnology drug delivery systems.
Radiological– Chelators, radioprotective agents, cytokines (for bone marrow suppression/ dysfunction) – may also be used for radiomimetic effects of mustard agents), bioassays, including chromosome/ cytogenetic analysis.
Nuclear– Novel burn treatments,novel decontamination products and processes.
In the U.S., the Biomedical Advanced Research and Development Authority, is the biomedical countermeasures research and development arm of the US Department of Health and Human Services – Assistant Secretary for Preparedness and Emergency Response (DHHS-ASPER). BARDA allows for collaboration of industry and academia and assists in the selection of countermeasures for various threats.
BARDA ‘s programs include:
– CBRN
– Antimicrobial resistance (AMR)
– Pandemic influenza (PI)
– Emerging infectious diseases (EID)
IMPACT AREAS
– Device(s)
-Therapeutics
-Vaccines
The US Food and Drug Administration is also involved in the process by administering safety and efficacy studies related to biomedical countermeasures and makes recommendations for Emergency Use Authorizations. (EUAs).
The Strategic National Stockpile (SNS) is administered by DHHS- ASPER and consists of a variety of devices, therapeutics, vaccines, PPE and other vital equipment and supplies that can be staged and deployed in the event of natural and man – made disasters that overwhelm local and state resources.
The SNS cache can be deployed as 12 – hour Push Packs, Vendor Managed Inventory (VMI) and a component known as Chempacks are pre- positioned in some US cities for the rapid availability and administration of nerve agent countermeasures in the event of a chemoterrorism event involving mass casualties due to nerve agent toxicity.
SNS assets are accompanied by a specialized team designed to facilitate the deployment, coordination and and distribution of medical countermeasures via public health department resources and health care stakeholders.
SNS assets are strategically positioned in areas of tbe U.S.at undisclosed sites and are maintained under tight security and environmental controls.
The SNS can be requested via state health departments and through State Governors offices to the HHS. In the interest of the international aspects of medical and public health readiness and emergency response, it is imperative that individual nation- states assess, develop and implement their own strategic medical response capacities and capabilities, including national caches of biomedical countermeasures. As a brutal war rages on in the Ukraine, we are reminded of the graphic images of mass injuries and illness and, including the destruction of the medical and public health infrastructure of an entire nation, and the dire needs for medical supplies and equipment.
Strategic warfare and terrorism can include the use of non – conventional CBRN weapons anywhere in the world or a novel viral strain can quickly manifest itself as a global pandemic. In the interest of global health security, we must be prepared to mitigate and respond to the broad spectrum of natural and man-made threats.
Authors: Bio
Frank Rando currently serves as an allied health programs educator / lead instructor and healthcare emergency preparedness/medical readiness /public health preparedness and tactical, operational – disaster medicine and homeland security Subject Matter Expert , educator , instructor and curriculum designer. He has served in instructional, guest speaker and consultative roles for DHS-FEMA, various components of the National Domestic Preparedness Consortium , DoD, industry, academia , health , safety and regulatory entities, emergency services organizations and healthcare.
He recently served during the COVID-19 public health emergency as a clinician and clinical researcher and also served in medical and health care support as a clinician for US Customs and Border Protection.
Frank is also an experienced clinician, first responder and an occupational – environmental health scientist with real world experience in hazardous materials management , hazards and pollution control, biosafety, industrial ,environmental and inhalation toxicology, environmental epidemiology ,exposure and risk assessment and emergency response . Frank has also received advanced training in Integrated Biological -Chemical Response from the US Army -Dugway West Desert Test Center and the National Ebola and Special Pathogens Training Centers.
Frank’s experience includes public safety roles in law enforcement, pre-hospital medicine/EMS and military duty as a Nuclear, Biological and Chemical/CBRN Specialist, NBC medical defense instructor Special Forces Medical Sergeant, Dive Medical Technician, Intelligence Sergeant and Medical Intelligence Analyst.
Dee Ruelas possesses over 35 years of dedicated professional experience in various roles in public safety/ emergency services, teaching and instruction, healthcare, environmental health and safety, emergency preparedness, community resiliency and Christian ministry. Dee was also a decorated public safety-emergency medical communications specialist for the City of Tucson Fire Department and worked for the Tucson Municipal Court, where one of her roles was serving as the Fire Prevention and General Safety Officer for the municipal courts system. Currently, Dee has been serving as a clinical specialist in COVID-19 testing and vaccination services and served as a medical and healthcare support specialist for US Customs and Border Protection.
Dee is the former Director of the City of Tucson Community Emergency Response Team (CERT) and is a DHS-Certified CERT Instructor, National Association of Emergency Medical Technician Tactical Emergency Casualty Care (TECC) Instructor and a Certified Stop the Bleed Instructor. Dee is also trained and serves as an experienced instructor and consultant in hazardous materials, incident command, explosives recognition, medical decontamination, active shooter countermeasures, emerging infectious diseases, mental health first aid, refugee medicine and general health and safety, including roles as a subject matter expert, guest speaker, and instructor for the State of Arizona Division of Occupational Safety and Health.
She has also been trained by the National Ebola Training Center and the Emory University Rollins School of Public Health Dee also is the owner and senior proprietor for Teach 2 Prepare, a consultancy and training entity.
