Page 53 - JSOM Fall 2021

Chemical Warfare Agents in Terrorist Attacks

An Interregional Comparison, Tactical Response Implications,
and the Emergence of Counterterrorism Medicine

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Derrick Tin, MBBS *; Matt Pepper, MPhil ; Alexander Hart, MD ;
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Attila Hertelendy, PhD ; Gregory Ciottone, MD 5

ABSTRACT
Background: Terrorist attacks are growing in frequency, in- only Egypt, North Korea, and South Sudan as non-signatory
creasing concerns about chemical warfare agents (CWAs). As- states. It is estimated that 98.37% of the world’s declared
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phyxiants (e.g., cyanide), opioids (e.g., carfentanyl), and nerve chemical weapons stockpiles have been destroyed. 3
agents (e.g., ricin) represent some of the most lethal CWAs. Our
aim was to define the epidemiology of CWA use in terrorism The threat of nonstate actors such as terrorist organizations
and detail specific agents used to allow for the development of using CWAs as weapons, however, remains a significant global
training programs for responders. Methods: The open-source challenge. A CWA is defined as a chemical substance whose
Global Terrorism Database (GTD) was searched for all chemical toxic properties are used to kill, injure, or incapacitate hu-
attacks from January 1, 1970, to December 31, 2018. Attacks man beings. The use of ammonium nitrate in the Oklahoma
were included when they fulfilled the terrorism-related criteria bombing of 1995, which killed 168 people, remains to date
as set forth in the internal Codebook of the GTD. Events meet- the deadliest act of domestic terrorism in the United States. 4
ing only partial criteria were excluded. Results: A total of 347
terrorism-related chemical events occurred, with 921 fatalities Homegrown, right-wing extremist organizations as well as
and 13,361 nonfatal injuries (NFIs) recorded during the study transnational terrorism are on the rise, with increasingly so-
period. South Asia accounted for nearly 30% (101 of 347) of phisticated attack methodologies being explored. Healthcare
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CWA attacks, with 73 of 101 occurring in Afghanistan. The vulnerabilities and education gaps in response to increasingly
Taliban was implicated in 40 of 101 events utilizing a mixture complex natural as well as manmade terrorist-related disasters
of agents, including unknown chemical gases (likely represent- have been at the forefront of discussions among disaster med-
ing trials of a number of different chemicals), contamination icine specialists, leading to the establishment of counterterror-
of water sources with pesticides, and the use of corrosive acid. ism medicine as a disaster medicine subspecialty. 6-8
The largest death toll from a single event (200 fatalities) was
attributed to a cult-related mass murder in the Kasese District of The aim of this study was to provide the historical epide-
Uganda in March 2000. East Asia sustained the highest NFI toll miology of global CWA use in terrorism, thereby allowing
of 7,007 as a result of chemical attacks; 5,500 were attributed healthcare responders to be better informed about the unique
to the Tokyo subway sarin gas attack of 1995 by Aum Shinri- toxidromes and injuries they may encounter. These data will
kyo. Conclusion: The use of CWAs remains a concern given the also be useful in the development of training programs in
rising rate of terrorist events. First responders and healthcare counter-terrorism medicine.
workers should be aware of potential chemical hazards that
have been used regionally and globally and should train and
prepare to respond appropriately. Methods
Data collection was performed using a database search
Keywords: chemical warfare agents; terrorist attacks; counter- through retrospective data from the GTD. This database is
terrorism medicine open access with a publicly available data collection method-
ology, including artificial intelligence identifying events daily
from news media around the world, as well as human evalu-
ation of the events by the National Consortium for the Study
Introduction
of Terrorism and Responses to Terrorism (START). The GTD
The Chemical Weapons Convention Implementation Act was searched using the internal database search functions for
of 1997 prohibits the large-scale use, development, produc- all chemical attacks that occurred between January 1, 1970,
tion, stockpiling, and transfer of chemical weapons. While and December 31, 2018. The GTD extends only as far back as
limited production is permitted for research and medical or 1970, and the years 2019 and 2020 were not yet available at
pharmaceutical purposes, member states have the additional the time of the study. Given the comprehensive methodology
obligation to destroy all current chemical weapons stockpiles of the GTD database and its use in the determination of a
under the supervision of the Organisation for the Prohibition number of other important measures of terrorism globally, the
of Chemical Weapons (OPCW). To date, 193 states are sig- GTD was considered the appropriate database for this review,
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natories to the Chemical Weapons Convention treaty, with as opposed to a de novo search of lay news articles.
*Correspondence to derrick@alphazodiac.com
1 Derrick Tin, Alexander Hart, Attila Hertelendy, and Gregory Ciottone are affiliated with the Department of Emergency and Disaster Medi-
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cine, Harvard Medical School, Boston, MA. Matt Pepper is affiliated with the Australian Tactical Medical Association.
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