Selected topic: Disaster medicine
Enhancing Public Health Preparedness for a Terrorist Attack Involving Cyanide

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Abstract

The US government considers cyanide to be among the most likely agents of chemical terrorism. Cyanide differs from many other biological or chemical agents for which little or no defense is available because its individual and public health effects are largely remediable through appropriate preparedness and response. Because the toxicity of the cyanide antidote currently available in the United States renders it ill-suited for use in terrorist incidents and other situations requiring rapid out-of-hospital treatment, hydroxocobalamin—an effective and safe cyanide antidote being used in other countries—has been introduced in the United States. Unlike the other available cyanide antidote, hydroxocobalamin can be administered at the scene of a cyanide disaster, and it need not be reserved for cases of confirmed cyanide poisoning but can be administered in cases of suspected poisoning. Both of these attributes facilitate the rapid intervention necessary for saving lives. To realize the potential benefits of hydroxocobalamin, progress also needs to be realized in other aspects of readiness, including but not limited to developing plans for ensuring local and regional availability of antidote, educating emergency responders and health care professionals in the recognition and management of cyanide poisoning, and raising public awareness of the potential for a chemical weapons attack and of how to respond.

Introduction

US governmental agencies, including the Centers for Disease Control and Prevention (CDC) and the Department of Homeland Security, consider cyanide to be among the most likely agents of chemical terrorism (1, 2). One of the most rapidly acting poisons, cyanide shares several characteristics of other chemical agents—such as sarin and chlorine—that render it a useful and effective tool for terrorists (3, 4, 5, 6, 7). It is easy to obtain, plentiful, does not require a great deal of knowledge to use, is capable of causing mass incapacitation and casualties, and is particularly effective when released within an enclosed space or ventilation system. In contrast to many biological agents such as smallpox or anthrax, for which vaccinations or antibiotics exist to prevent disease after exposure, the effects of chemical weapons are typically immediate. Rapid availability of an effective antidote is essential to treat patients with moderate or significant exposure. Although the capability for limiting the impact of a cyanide event exists, the United States is insufficiently prepared to capitalize on this capability and remains unprepared for a potential cyanide disaster (8). This article discusses cyanide as a potential weapon of chemical terrorism and considers, from a public health perspective, strategies for enhancing preparedness for a cyanide disaster.

Section snippets

Forms and Sources of Cyanide

Cyanide exists in several forms, including the gases hydrogen cyanide and cyanogen chloride, soluble cyanide salts, and insoluble cyanide salts (Table 1) (9, 10). Both gaseous and solid forms are extensively used, often in very large quantities, in industry. Cyanide is used in the recovery of gold and silver from mineral ores and of silver from photographic materials; in the production of plastics, pigments, and dyes; and as a pesticide (8, 9). Moreover, hydrogen cyanide is released as a

Cyanide as a Potential Chemical Weapon

Most literature on cyanide as a terrorist weapon focuses on the possibility of intentional release of the gaseous form, particularly hydrogen cyanide, into enclosed spaces such as office buildings or stadiums (5, 6, 7). A less salient but perhaps more likely source of cyanide in a terrorist attack, release of hydrogen cyanide as a combustion product in closed-space fires, should be considered among the probable outcomes of any terrorist attack involving fire (Table 2). Exposure to hydrogen

Recent History of Use of Cyanide as a Weapon

The utility of cyanide as a weapon is illustrated by its recent history of actual and planned use in intentional poisoning. Cyanide has been used as a murder weapon, as a weapon of war, as a poison in individual and mass suicides and attempted genocide, and in several recently attempted terrorist incidents (Table 4) (4, 13, 15, 16). The range of settings in which cyanide was used and its various modes of delivery in the examples listed in Table 4 illustrate the versatility of cyanide as a

Enhancing Preparedness for Terrorist Attacks Involving Cyanide

Given the versatility, easy accessibility, and lethality of cyanide and its apparent familiarity to modern terrorists, a terrorist attack involving cyanide may be a likely event in the United States. With appropriate preparedness, however, the public health threat posed by cyanide poisoning—unlike that posed by many other biological and chemical weapons—can be contained to a large extent. Containment is possible because:

  • 1

    Signs and symptoms of poisoning are manifested instantaneously and

Conclusions

In a June 2001 article assessing public health readiness for cyanide disasters, authors Samual Sauer of the US Army Medical Corps and The School of Public Health at the University of Hawaii and Mark Keim of the CDC and the Department of Emergency Medicine at Emory University characterized the US state of preparedness for a cyanide disaster as abysmal and suggested that:

We, as a nation, are simply not prepared for a significant cyanide-related event. The standard of care for cyanide intoxication

Acknowledgments

The author thanks Jane Saiers, PHD, for assistance with writing this manuscript. Dr. Saiers' and the author's work on this manuscript was supported by EMD Pharmaceuticals, an affiliate of Merck KGaA.

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