The threat of chemical, biological, radiologic, nuclear, and explosive (CBRNe) terrorist attacks has increased over time. The need for rapid and effective responses to such attacks is paramount. Effective medical counter-measures to CBRNe events are critical and training for such may effectively occur early in physician training. While some medical specialties are more involved than others, counter-terrorism medicine (CTM) spans all medical specialties.

All United States allopathic medical schools were examined via online curriculums and queries for academic content related to CBRNe and terrorist medical counter-measures.

Analysis of 153 United States allopathic medical schools demonstrated that 15 (9.8%) medical schools offered educational content related to CBRNe and terrorist counter-measures. This is in contrast to legislation following the September 11, 2001 attacks that called for high priority for such education.

Effective CBRNe medical counter-measures are currently in place; however, there is room for improvement in education that may begin during medical school. While certain medical specialties such as emergency medicine, primary care, and dermatology may have specific niches in such events, physicians of all medical specialties have something to offer, and even a basic education in medical school can help best prepare the nation for future attacks.

The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events.

Data collection was performed using a retrospective database search through the VNSA CBRN Event database.

A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents.

Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

The use of chemical weapons in terrorist attacks, though rare, remains a significant challenge and concern due to their ability to inflict mass casualties. Chemical attacks remain a topic of interest for Disaster Medicine (DM) and Counter-Terrorism Medicine (CTM) specialists and are clearly an area in need of enhanced preparedness. This study aims to provide an epidemiological description of all terrorism-related attacks using chemical agents as a primary weapon, sustained from 1970 - 2019. These data will be useful in the development of education programs in CTM and provide an insight into how best to prepare for potential attacks in the future.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events using chemical weapons as a primary attack method from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. The GTD also details the specific chemical used, when known, in the summary of incidents. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

A total of 292 terrorist attacks involving chemical agents as a primary attack method were recorded from 1970 - 2019, registering 284 deaths and 13,267 injuries. Acid (52) was the most commonly used chemical agent, followed by “unspecified poison” (43), “unknown chemical agents” (29), “unspecified gas” (27), tear gas (27), chlorine gas (24), cyanide (21), mercury (9), pepper spray or mace (9), mustard gas (8), insecticide or 1080 (8), diphenylamine chloroarsine (7), phosphate or phosphorous (3), sodium hydroxide or corrosive liquid (3), sarin (2), “unspecified drugs” (2), VX nerve gas and other nerve gas (2), pesticides (2), cleaning chemicals/paint thinner (2), ammonia (2), anesthesia agent (1), arsenic (1), chlorine and mustard gas mix (1), phenarsazine chloride (1), rat poison (1), unknown irritative gas (1), hydrochloric acid and sodium cyanide mix (1), unknown white powder (1), antiseptic dye (1), and chlorine gas and white phosphorous mix (1).

The use of chemical weapons in warfare, though prohibited by the Chemical Weapons Convention (CWC), remains a rare but concerning terrorist attack methodology. In recent years, there have been more instances where potentially deadly chemicals have been used in civilian settings. Dual use industrial chemicals, in particular, pose a significant concern. Acid was the most commonly used chemical weapon in 52 attacks. Tear gas, chlorine, and cyanide were each used in over 20 attacks. Both DM and CTM specialists advocate for better preparedness and response training for intentional events in civilian settings.

High profile terrorist attacks in major capital cities have seemingly become a regular occurrence and the resultant mass-casualty events continue to challenge health care systems. Counter-Terrorism Medicine (CTM) addresses unique terrorism-related issues relating to the mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks. This study is an epidemiological examination of all terrorism-related events sustained from 1970-2019, analyzing historical weapon types used and the resulting fatal injuries (FI) and non-fatal injuries (NFI) sustained.

The Global Terrorism Database (GTD) was searched for all attacks from 1970-2019. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria, as set by the GTD codebook. Ambiguous events were excluded. State-sponsored terrorist events do not meet the codebook’s definition, and as such, are excluded from the study. Available counts of FI and NFI in each incident were then sorted and aggregated by weapon type to enable mean and standard deviation calculations.

In total, 168,003 events were recorded from the years 1970-2019. Explosives, bombs, and/or dynamite (E/B/D) were the most commonly used weapon type and accounted for 48.78% of all terrorism events, followed by the use of firearms in 26.77% of events. A total of 339,435 FI and 496,225 NFI resulted from all terrorism events that occurred during the study period. Combined, E/B/D and firearms accounted for 75.55% of all events, 67.1% of all FI, and 79.3% of all NFI. Each individual terrorism event inflicted a mean FI rate of 2.14 FI per event (SD = 10.2) and a mean NFI rate of 3.22 NFI per event (SD = 45.19).

Although terrorism is complex and does not solely rely on death tolls as a measure of success, this analysis shows a historic mean FI rate of 2.14 and NFI rate of 3.22 per event over the past 50 years. Proven weapons such as E/B/D and firearms combine to account for over 75% of weapon types used in all events. Use of weapons of mass destruction (WMDs) such as chemical, biological, radiation, and nuclear (CBRN) weapons has been rare (0.2%), yet has extreme high potential to inflict mass casualties with mean NFI rates of 49.62 and 28.75 for chemical and biological weapons, respectively.

A Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.

Challenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).

Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.

This study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.

The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.

RazakS, HignettS, BarnesJ. Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review. Prehosp Disaster Med. 2018;33(5):543–549.