A-8. Effects of Biological Weapons

(2) Toxins have several desirable traits. They are poisonous compounds that do not grow, reproduce, or die after they have been dispersed; they are more easily controlled than live organisms. Field monitors capable of providing prompt warning of a toxin attack are not available; therefore, personnel must learn to quickly recognize signs of attack, such as observing unexplained symptoms of victims. Toxins produce effects similar to those caused by chemical agents; however, the victims will not respond to the first-aid measures that work against chemical agents. Unlike live agents, mycotoxins (T2) can penetrate intact skin; other toxins cannot. Because the effects on the body are direct, the symptoms of an attack may appear very rapidly. The potency of most toxins is such that very small doses will cause injuries and/or death. Thus, their use by an enemy may be an alternative to chemical agents because it allows the use of fewer resources to cover the same or a larger area. Slight exposure at the edges of an attack area may produce severe symptoms or death from exposure to toxins because of their extreme toxicity. Lethal or injury downwind hazard zones for toxins may be far greater than those of CW agents.

A-9. Behavior of Biological Weapons

Biological agents can be disseminated in a spectrum of physical states. They may be living microorganisms or spore forms of the organism. See Table A-11 for stability of various biological agents. They may be spread by—

• Arthropods.
• Contact with infected animals.
• Contamination of food and water.
• Aerosol, liquid, or solid dispersion.

The only requirement is that they must be stable enough to survive transport and dissemination. The toxicity of biological agents is not the same for everyone; each individual does not react exactly the same way to the same amount of an agent. Some are more resistive than others because of race, sex, age, or other factors. The dose is the quantity of a biological agent received by the subject. The penetration of agents by various routes need not be accompanied by irritation or damage to the absorbent surface. There are often unique signs and identifying symptoms depending on entry route (inhalation, ingestion, or dermal).

a. Biological agents dispersed by spray often enter the body through the respiratory tract (inhalation injury). The agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs.

b. Liquid droplets and (less commonly) solids may be absorbed from the surface of the skin, digestive tract, and mucous membranes. Agents penetrating the skin may form temporary reservoirs under the skin.

c. Contaminated food and water can produce casualties when ingested.

Table A-11. Types and Characteristics of Some Biological Agents

A-10. Management of Biological Warfare Patients

c. Decontamination. Decontamination is an individual and unit responsibility. However, some individuals may arrive at the MTF that have not been decontaminated or that become contaminated en route to the MTF. These individuals must be decontaminated at the MTF before they are admitted to prevent contamination of the MTF and exposure of medical personnel to the biological agent. See Appendix G for details on patient decontamination.

d. Treatment. Specific treatment is dependent upon the BW agent used. Patients are treated for symptomatic presentation unless the BW agent identity is known. Field Manuals 8-9 and 8-284 provide detailed information on medical management and treatment.

A-11. Effects of Chemical Weapons

A-12. Behavior of Chemical Weapons

Chemical agents can be disseminated as a gas, vapor, or aerosol under ambient conditions. They have a range of odors varying from none to highly pungent characteristics. Their stability is dependent upon the environmental conditions in the area of employment. See Table A-11 for persistency of various chemical agents.

a. The toxicity of a chemical agent is not the same for everyone; each individual does not react exactly the same way to the same amount of an agent. Some are more resistant than others because of physiological factors. The dose is the quantity of a chemical received by the individual for percutaneous or oral doses and as a time-weighted concentration, milligrams-minute (m3), for inhalation. It is usually expressed as milligrams of agent per kilogram of subject body weight (mg/kg). The LD50 is the dose that kills 50 percent of the exposed population. The incapacitation dose 50 (ID50) is the incapacitation dose for 50 percent of the exposed subjects. The penetration of agents by various routes need not be accompanied by irritation or delayed superficial damage to the absorbent surface, but there are often unique signs and symptoms identifiable by the route of entry.

(1) Gaseous, vapor, and aerosol chemical agents often enter the body through the respiratory tract (inhalation injury). The agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs. Aerosol particles larger than 5 μ tend to be retained in the upper respiratory tract; particles in the 1 to 5 μ range are retained in the deep volume of the lungs; while those below 1 μ tend to be breathed in and out again; although a few are retained in the deep volume of the lungs.

(2) Vapors and droplets of liquids can be absorbed from the surface of the skin and mucous membranes. Toxic compounds that are harmful to the skin can produce their effects in liquid or solid state. Agents penetrating the skin may form temporary reservoirs under the skin; the vapors of some volatile liquids can penetrate the skin and cause intoxication. Additionally, wounds and abrasions may present areas that are more permeable than intact skin.

b. Chemical agents may be divided into two main categories (persistent and nonpersistent) that describe how long they are capable of producing casualties. Table A-12 lists the common chemical agents, their effects and time of effectiveness. Table A-13 lists the types and characteristics of common chemical agents.

(1) Persistent agents continue to present a hazard for considerable periods (days) after delivery by remaining as a contact hazard, or by slowly vaporizing to produce a hazard by inhalation.

(2) Nonpersistent agents disperse rapidly after release and present an immediate, short duration (hours) hazard. They are released as airborne particles, aerosols, and gases.

Table A-12. Common Chemical Warfare Agents

Table A-13. Types and Characteristics of Chemical Agents

A-13. Characteristics of Chemical Agents

(2) Nerve agents strongly inhibit the cholinesterase enzymes. When acetylcholine is released by the nerve junction, it is hydrolyzed by the enzyme. Acetylcholine is the chemical mediator for transmission of the nerve impulses in numerous synapses of the central nervous system (CNS) and the autonomic nervous system and at the endings of the cholinergic nerves (for example: affecting the smooth muscles of the iris, ciliary, bronchial tree, and gastrointestinal tract). The inhibition of cholinesterase by nerve agents is almost irreversible, so the effects are prolonged. Until the cholinesterase level is restored to normal, there is an increased susceptibility to nerve agent exposure. During this time, the effects of repeated exposure are cumulative and the patient may feel "subpar" (for example: tired, fatigue easily, poor appetite, impaired concentration) until recovery is complete.

(3) Nerve agent poisoning is easily identified by the characteristic signs and symptoms as follows:

(a) MILD symptoms (self-aid). Casualties with MILD symptoms may experience most or all of the following:

• Unexplained runny nose.
• Unexplained sudden headache.
• Sudden drooling.
• Difficulty in seeing (dimness of vision) (miosis).
• Tightness in the chest or difficulty in breathing.
• Localized sweating and muscular twitching in the contaminated area.
• Stomach cramps.
• Nausea.

(b) Casualties with MODERATE symptoms (buddy aid) will experience an increase in the severity of most or all of the MILD symptoms. Especially prominent will be an increase in fatigue, weakness, and muscle fasciculations. The progress of symptoms from MILD to MODERATE indicates either inadequate atropine treatment or continuing exposure to agent.

(c) SEVERE symptoms (buddy aid). Casualties with SEVERE symptoms may experience most or all of the MILD symptoms, plus most or all of the following:

• Strange or confused behavior.
• Wheezing, dyspnea (severe difficulty in breathing), and coughing.
• Severely pinpointed pupils.
• Red eyes with tearing.
• Vomiting.
• Severe muscular twitching and general weakness.
• Involuntary urination and defecation.
• Convulsions.
• Unconsciousness.
• Respiratory failure.

b. There are three major families of blister agents (vesicants); HD and HN, L, and CX. Most vesicants (except CX) are relatively persistent. Mustards can modify the structure of nucleic acids, cellular membranes, and proteins by combining with certain functional groups (particularly the sulfhydryl-containing enzymes) for which they have an affinity.

(1) The cutaneous syndrome is divided into four phases: latent, erythema, vesication, and necrosis. Vesicants can penetrate the skin by contact with either liquid or vapor. The latent period is characteristic of the agent. For mustards it is usually several hours, for L it is short, and for CX it is negligible. The latent period is also affected by the dose, temperature, and humidity. The symptoms of the erythema phase are red, painful itching followed by painful necrosis that heals slowly.

(2) In the eyes, vesicants produce intense pain and photophobia. Blistering of the eyelids and mucous membranes can result in temporary blindness. Even after recovery, scars on the cornea can reduce visual acuity.

(3) In the respiratory tract, these agents attack the mucous membranes irritating them. They can paralyze vocal chords and can lead to chemical pneumonitis, or possibly death.

(4) Although blister agents can affect other organs and produce deleterious effects, the skin, eyes, and respiratory tract are the principle organs effected.

c. Chemical agents that attack lung tissue (choking agents) and cause pulmonary edema are classed as lung damaging agents. Choking agents consist of CG and DP, CL, and PS. Phosgene is typical of the lung-damaging agents; it is used as the example here.

(1) Phosgene is a colorless gas that has an odor resembling new mown hay. Although effects are primarily confined to the lungs, phosgene may also cause mild irritation of the eyes and upper respiratory tract. Phosgene causes a shift in the membrane potential of the alveoli allowing the passage of fluid into the alveoli, resulting in massive pulmonary edema and severely impairing the exchange of oxygen (O₂) and carbon dioxide (CO₂) between the capillary blood and the alveolar air.

(2) Initially hypoxemia occurs and is followed shortly by hyperventilation when the frothy edema fluid fills the bronchioli and CO₂ expiration stops.

(3) Signs and symptoms during and immediately following exposure are coughing, tightness of chest, nausea, occasionally vomiting, headache, and lacrimation (tearing).

d. Blood agents consist of AC and CK; both are readily absorbed by the mucous membranes and the intact skin. The odor of AC resembles bitter almonds, but many people cannot detect it. Detecting the odor of CK is difficult because of its irritating and lacrimatory effects. It is also poorly absorbed by the metallic salt-impregnated charcoal filters in the protective mask. These agents inhibit certain enzymes (particularly cytochrome oxidase) that are important for oxidation-reduction in the cells; therefore, cell respiration is inhibited and oxygen carried by the hemoglobin is not consumed causing the venous blood to remain bright red. Initial symptoms are characterized by violent convulsions, increased deep respiratory movements, followed by cessation of respiration within one minute, slowing of heart rate to death. High concentrations exert their effects rapidly; however, if the patient is still alive after the cloud has passed, he will probably recover spontaneously.

e. Incapacitating agents are chemicals that produce a temporary disabling condition that persists for hours to days after exposure to the agent has ceased (unlike that produced by riot control agents). While not required, medical treatment produces a more rapid recovery. Characteristics of these agents are that they—

• Are highly potent and logistically feasible.
• Produce their effects mainly by altering or disrupting the higher regulatory activity of the CNS.
• Produce effects that last for hours or days rather than momentary or fleeting.
• Do not seriously endanger life, except in exceedingly high doses.
• Produce no permanent injury.

The two types likely to be encountered are CNS depressants and CNS stimulants.

(1) Central nervous system depressants are compounds that have a predominant effect of depressing or blocking the activity of the CNS; often by interfering with the transmission of information across synapses. An example of this type of agent is BZ. The action of acetylcholine, both peripherally and centrally, appears to be blocked by BZ. Low doses disrupt higher integrative functions of memory, problem solving, attention, and comprehension. High doses produce toxic delirium that destroys the ability to perform any military task. Within the CNS, BZ seems to produce its effects in the same way as atropine. Small doses cause sleepiness and decreased alertness with elevated heart rate, dry skin and eyelids, drowsiness, increased pupil size, and elevated skin temperatures. Progressive intoxication is marked by an inability to respond effectively to the environment (4 to 12 hours), followed by increasing activity and random/unpredictable behavior (12 to 96 hours). Because the patient cannot sweat, heat stress becomes a problem.

(2) Central nervous system stimulants are agents that cause excessive nervous activity, often by boosting or facilitating transmission of impulses across synapses. The effect is to "flood" the cortex and other higher regulatory centers with too much information, making concentration difficult and causing indecisiveness and an inability to act. These include LSD, psilocybin, and mescaline. Intoxication shows sympathetic stimulation (rapid heart rate, sweaty palms, pupillar enlargement, and cold extremities) and mental excitation (nervousness, trembling, anxiety, and inability to relax or sleep); feelings of tension, exhilaration, heightened awareness, paranoid ideas, and profound states of terror may also occur.

A-14. Management of Chemical Agent Patients

c. Decontamination. Decontamination is an individual and unit responsibility. However, some individuals may arrive at the MTF that have not been decontaminated or that become contaminated en route to the MTF. These individuals must be decontaminated at the MTF before they are admitted to prevent contamination of the MTF and exposure of medical personnel to the chemical. See Appendix G for detailed information on patient decontamination procedures.

d. Treatment. Field Manuals 8-9 and 8-285 provide treatment procedures for chemical agent patients.

A-15. Management of Toxic Industrial Material Patients

EXAMPLE: Treatment for a casualty exposed to toxic levels of an inorganic phosphate pesticide would be treated in the same manner as a nerve agent casualty except the amount of antidote for the pesticide poisoned casualty will be many times greater than for the nerve agent casualty.

APPENDIX B

SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT

Section I. INTRODUCTION

B-1. General

c. Coordination for follow-on testing is absolutely critical to the sample/specimen collection process.

d. Coordination with the receiving laboratory should be made to establish sample requirements, preferred collection techniques, methods of preservation, and transportation conditions, when the tactical situation and/or mission permits.

e. The number of medical specimens that need to be collected varies with the type of analysis performed and the impact of the values determined. The number and types of "control" samples/specimens required to validate test information is determined by the supporting medical laboratory personnel. Random sampling, matched with control populations, or other techniques will be employed as the requirements are identified.

B-2. Sample/Specimen Background Information

• Meteorological conditions. Describe what the meteorological conditions were at the time of the alleged attack and at the time of the sampling.
• Attack to collection time. State the length of time after alleged attack when sample/specimen was taken.
• Circumstances of acquisition. Describe how the sample/specimen was obtained and the source of the sample/specimen.
• Physical description. Describe the physical state of the sample/specimen (solid, liquid, powder, apparent viscosity), color, approximate size, identity of the sample/specimen (that is, dirt, leaves, blood, tissue), and dose rate (if radiologically contaminated).
• Circumstances of the agent deposition. Describe the type of delivery system, a description of how the weapon functioned, how the agent acted on release, sounds heard during dissemination, a description of any craters or shrapnel found associated with the burst, and colors of smoke, flames, or mists that may be associated with the attack.
• Agent effects on vegetation. Describe the general area (jungle, mountain, grassland) and changes in the vegetation after the agent deposition (that is, color change, wilting, drying, dead) in the main attack and fringe areas.
• Agent effects on humans. How the agent affected personnel in the main attack area versus fringe areas; the duration of agent effects; peculiar odors that may have been noticed in the area before, during, or after an attack; measures taken that alleviated or worsened the effects; and the approximate number of victims and survivors (include age and gender).
• Agent effects on animals. Describe how they are affected.
• Grid coordinates or other descriptive information on sample collection location.

B-3. Sample/Specimen Collection and Preservation

a. Ante mortem Specimens. Physiological specimens from living human or animal patients can include just about any conceivable body source or excreted by-product. It must be noted that specimen types are seldom interchangeable; the exact type and amount of specimen required for a specific assay must be known before a collection procedure is initiated (see Table B-1).

• Patients seen in an MTF may be the first and in some cases the only source for sampling for suspect biological agent release. The primary medical care provider will determine the level of treatment for these patients and the specimens required for laboratory diagnosis. The MTF laboratory is not equipped to handle biological agents and, therefore, specimens generated will be forwarded to the supporting medical laboratory for analysis. Patient disposition will be based on evacuation policies, exposure, suspect agent, clinical symptoms, and required treatment/isolation.
• Blood specimens represent the most common analytical sample. Certain techniques and special care must be exercised to ensure an acceptable specimen is collected and to minimize an adverse affect to the patient or specimen collector. In general, phlebotomy requires the use of a 20 to 22-gauge needle to minimize mechanical hemolysis during aspiration using a syringe or Vacutainer^TM tube collection system. Blood collected with a syringe and needle should be transferred to an appropriate Vacutainer^TM tube immediately after collection. The type of tube, type of anticoagulant or preservative, and amount of blood collected will vary with the specific assay requested. Unless some special sample preparation step is required, the blood is best left in the original rubber-stopper tube for transport.
• Urine specimens are best collected using a clean-catch (midstream, if possible) technique in a sterile urine cup. The volume of sample required will vary depending on the specific assay requested; however, 25 to 50 ml is sufficient for most tests.
• Tissue specimens can originate from any body source accessible by scraping, swabbing, or minor excision. Tissue specimens are collected only by medical trained personnel. Specific techniques for collecting these specimens are not provided in this appendix.
• Sputum specimens are best collected using a sterile cup. The volume of specimen will normally be very small. However, a sufficient quantity must be collected to provide for in-theater testing and to provide for CONUS laboratory testing.
• Nasal swabs should be collected using sterile cotton-tipped swabs. The swabs with specimen from each person should be placed in a separate sterile container to prevent cross-contamination.