Design and development of a prototype for specific naked-eye detection of blister and nerve agents.

In view of the strong need to strengthen the national security arising from chemical terrorism, a rapid, specific, and onsite detection of chemical warfare agents (CWAs) employing a simple and easy-to-use kit is of utmost importance. Constant and sincere efforts are being carried out by the scientific community to find reliable techniques/methods for early warning detection. Herein, we designed a prototype technique in the form of a smart and portable chemical weapon detection kit (CWDK) to facilitate rapid and onsite detection. In this portable kit, a range of unique chemical probes were condensed to achieve the specific chromogenic and fluorogenic detection and discrimination of each member of blister and nerve agents. The embodiment of three chemical probes (Fc, SQ, and LH2) was eventually employed in a compact and flexible plastic packaging for detecting the presence of CWAs with the 'naked-eye' in the areas where laboratory services do not normally exist. The CWDK contains dye/reagent vials, sampling assembly, and a UV torch. The convenience and practicality of this technique suggest a great prospect for highly specific sensing of the complete class of CWAs with fast and accurate results in real-time scenarios with a sensitivity much below their lethal dose.

Stability of Diazepam Solution for Injection Following Long-Term Storage in an Ambient Temperature of the Mediterranean Climate.

PURPOSE: Diazepam is utilized as a convulsion antidote following nerve gas attacks. As an emergency medicine, it requires storage at ambient temperatures which often doesn't meet manufacturers' requirements, leading to an early invalidation of the product. Current work investigated this issue. METHODS: Long-term stability of diazepam ampoules for injection stored in an ambient temperature of the Mediterranean climate for ~10 years vs storage at room temperature was studied. RESULTS: Diazepam assay and pH remained within pharmacopeial specifications irrespective of storage conditions. A major degradation product 2-methylamino-5-chlorobenzophenone (MACB) showed a clear trend of accumulation as a function of storage time, exceeding the permitted limit at ~2 years, irrespective of storage conditions. A strong correlation between the discoloration of the solutions and the concentration of MACB was obtained. Intravenous administration of MACB to rats at doses ~2200-fold higher than permissible specification levels caused neither mortality nor any toxicological nor post-mortem findings. CONCLUSIONS: Regarding the parameters tested: diazepam assay, MACB assay, and pH, storing ampoules of diazepam solution for injection in field conditions of high temperatures of the Mediterranean climate did not cause accelerated degradation as compared to room temperature. These findings open an option for the usage of expired ampoules in special scenarios.

Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness.

BACKGROUND: Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks. METHODS: A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017. RESULTS: 383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25%) where the route of exposure was known. Explosive devices were used in 21% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25% and 12% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0%), tear gas (20.8%), and cyanide (15.6%). Blood agent incidents declined from 32.6% before the September 11, 2001 attacks to 13.6% after 2001, while nerve agent attacks fell from 9.3% to 1.2%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7% to 48.1% and from 2.3% to 6.2% of attacks, respectively. CONCLUSIONS: Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.

No promising antidote 25 years after the Tokyo subway sarin attack: A review.

On the battlefields of Syria, many innocent civilians have been killed or injured by sarin poisoning. In Malaysia in February 2017, a North Korean man was assassinated with VX at Kuala Lumpur International Airport. In the face of such threats, a more effective antidote against organophosphonate acetylcholinesterase (AChE) inhibitors is needed, one that can freely penetrate into the central nervous system (CNS) through the blood-brain barrier (BBB). In the 1995 Tokyo subway sarin attack, which produced more than 6,000 victims, 2-pyridinealdoxime methiodide was the most commonly used antidote in hospitals, but it was unable to prevent CNS damage and no other oximes have been approved for use in Japan. Ultimately, 12 people died, and many victims had severe neurological injuries or sequelae. Although more than 25 years have passed since the incident, progress has been slow in the development of a new antidote that can penetrate the BBB, restore AChE activity in the CNS, and definitely prevent brain injury. From the perspectives of countering terrorism and protecting innocent people from nerve agent attacks, the search for nerve agent antidotes should be accelerated with the goals of improving both survival and quality of life. This review gives an overview of a series of our studies on the development of a new antidote since the Tokyo subway sarin attack and emphasizes that there is unfortunately still no promising antidote for saving the CNS in Japan.

The Tokyo subway sarin attack has long-term effects on survivors: A 10-year study started 5 years after the terrorist incident.

OBJECTIVES: The Tokyo subway sarin attack in 1995 was an unprecedented act of terrorism that killed 13 people and sickened more than 6,000. The long-term somatic and psychological effects on its victims remain unknown. METHODS: We conducted analyses on the self-rating questionnaire collected annually by the Recovery Support Center (RSC) during the period from 2000 to 2009. The RSC is the only organization that has large-scale follow-up data about sarin attack victims. The prevalence of self-reported symptoms was calculated over 10 years. We also evaluated the prevalence of posttraumatic stress response (PTSR), defined as a score ≥ 25 on the Japanese-language version of the Impact of Event Scale-Revised. The multivariate Poisson regression model was applied to estimate the risk ratios of age, gender, and year factor on the prevalence of PTSR. RESULTS: Subjects were 747 survivors (12% of the total) who responded to the annual questionnaire once or more during the study period. The prevalence of somatic symptoms, especially eye symptoms, was 60-80% and has not decreased. PTSR prevalence was 35.1%, and again there was no change with time. The multivariate Poisson regression model results revealed "old age" and "female" as independent risk factors, but the passage of time did not decrease the risk of PTSR. CONCLUSIONS: Although symptoms in most victims of the Tokyo subway sarin were transient, this large-scale follow-up data analysis revealed that survivors have been suffering from somatic and psychological long-term effects.

Modeling and Risk Analysis of Chemical Terrorist Attacks: A Bayesian Network Method.

The chemical terrorist attack is an unconventional form of terrorism with vast scope of influence, strong concealment, high technical means and severe consequences. Chemical terrorism risk refers to the uncertainty of the effects of terrorist organisations using toxic industrial chemicals/drugs and classic chemical weapons to attack the population. There are multiple risk factors infecting chemical terrorism risk, such as the threat degree of terrorist organisations, attraction of targets, city emergency response capabilities, and police defense capabilities. We have constructed a Bayesian network of chemical terrorist attacks to conduct risk analysis. The scenario analysis and sensitivity analysis are applied to validate the model and analyse the impact of the vital factor on the risk of chemical terrorist attacks. The results show that the model can be used for simulation and risk analysis of chemical terrorist attacks. In terms of controlling the risk of chemical terrorist attack, patrol and surveillance are less critical than security checks and police investigations. Security check is the most effective approach to decrease the probability of successful attacks. Different terrorist organisations have different degrees of threat, but the impacts of which are limited to the success of the attack. Weapon types and doses are sensitive to casualties, but it is the level of emergency response capabilities that dominates the changes in casualties. Due to the limited number of defensive resources, to get the best consequence, the priority of the deployment of defensive sources should be firstly given to governmental buildings, followed by commercial areas. These findings may provide the theoretical basis and method support for the combat of the public security department and the safety prevention decision of the risk management department.

Chemical-Biological Terrorism and Its Impact on Children.

Children are potential victims of chemical or biological terrorism. In recent years, children have been victims of terrorist acts such as the chemical attacks (2017-2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has broadened to an all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks (eg, natural events such as earthquakes or pandemic influenza or man-made catastrophes such as a hazardous-materials spill). In response to new principles and programs that have evolved over the last decade, this technical report supports the accompanying update of the American Academy of Pediatrics 2006 policy statement "Chemical-Biological Terrorism and its Impact on Children." The roles of the pediatrician and public health agencies continue to evolve, and only their coordinated readiness and response efforts will ensure that the medical and mental health needs of children will be met successfully. In this document, we will address chemical and biological incidents. Radiation disasters are addressed separately.

Chemical-Biological Terrorism and Its Impact on Children.

Chemical and biological events (including infectious disease outbreaks) may affect children disproportionately, and the threat of a chemical or biological attack remains in the United States and worldwide. Although federal programs and funding support a broad range of federal initiatives for public health preparedness and response, funding at the state and local levels has been flat or is decreasing, potentially leaving communities vulnerable. Consequently, pediatricians need to prepare and be ready to care for children in their communities before, during, and after a chemical or biological event, including during long-term recovery. Some medical countermeasures for particular chemical and biological agents have not been adequately studied or approved for children. The American Academy of Pediatrics provides resources and education on disaster preparedness and response, including information on the pediatrician's role in disasters, pediatric medical countermeasures, and mental health after an event as well as individual and family preparedness. This policy statement addresses the steps that clinicians and policy makers can take to protect children and mitigate the effects of a chemical or biological attack.

Evidence of sulfur mustard exposure in victims of chemical terrorism by detection of urinary ß-lyase metabolites.

Background: Sulfur mustard (SM) is a vesicant chemical warfare agent. Ocular, dermal, and respiratory systems are the primary targets of SM exposure. The aims of this study were to perform a quantitative analysis of ß-lyase metabolites of SM as 1,1'-sulfonylbis[2-(methylthio) ethane] (SBMTE) in urine samples of chemical casualties and to investigate the relationship between the measured SBMTE levels and the severity of characteristic symptoms of SM poisoning.Methods: A bioanalytical method which is based on titanium (III) chloride reduction of ß-lyase metabolites was employed to analyze urine samples of individuals (n = 13, collected 30 h after SM exposure) using gas chromatography-tandem mass spectrometry.Results: Various levels of SBMTE were measured in urine samples of seven individuals, confirming SM exposure for each. There was a correlation observed between measured levels of SBMTE in human urine samples and severity of clinical findings including ocular, respiratory, and cutaneous lesions of SM.Discussion: In combination with clinical examination, measurement of SBMTE levels in human urine could be used as a prognostic factor for clinical outcomes in victims of SM exposure. This bioanalytical verification is also important for the documentation of alleged use of SM.Conclusion: SBMTE is an unambiguous biomarker of potential SM poisoning as it does not exist in urine samples of an unexposed population. Quantitation of urinary SBMTE concentrations in victims of SM could be used in order to enable improved interpretation of clinical findings.

Myelosuppression and acute hematological complications of sulfur mustard exposure in victims of chemical terrorism.

Sulfur mustard (SM) is a vesicant chemical warfare agent. Recent studies reported alleged use of SM by non-state actors in Syria and Iraq. It has been shown that SM induced immunological and hematological complications. The aim of this study was to determine acute toxic effects of SM exposure on hematological parameters. Blood samples from a group of Syrian exposed to SM in 2016 were taken daily during the follow-up of the patients in intensive care unit. Initial leukocytosis was observed in all patients (100%) on the first 48 h after exposure. Following leukocytosis, isolated lymphopenia was observed in all patients (100%) between 2nd and 4th days. A decrease in hemoglobin level was noted in five patients (62.5%) between 4th and 5th days. Thrombocytopenia was observed in 75% of patients between 4th and 6th days for mild cases and between 9th and 11th days for severe cases. Three patients (37.5%) developed distinct leucopenia/neutropenia on 11th and 12th days. It was observed that human exposure to high dose of SM has direct toxic effect on hematological cells and bone marrow. New strategies on treatment of SM-induced myelosuppression could reduce the effects of hematological complications and could increase the survival rate in these patients.

Recent sulfur mustard attacks in Middle East and experience of health professionals.

Sulfur mustard (SM) is a vesicant chemical warfare agent which affects ocular, respiratory, and cutaneous system. In this study, we aimed to share recent experiences on medical management of chemical casualties that were exposed to SM in Middle East. We reported medical management of 17 contaminated patients. After the evacuation from the hot zone, all chemical casualties should be transferred to the designated intensive care units. After detailed medical decontamination and stabilization, biological samples should be collected from all chemical casualties as soon as possible for the verification of the exposure. Medical history and existing symptoms reveal the clinical diagnosis of SM exposure. Medical management of SM casualties should focus on "good nursing care" including treatment of pain and itching, fluid and electrolyte replacement therapy, respiration and nutrition support. Despite of improved clinical skills, treatment of SM lesions is still non-specific which aims to relieve symptoms and to prevent infections. Existing diagnostic capabilities and treatment approaches could be improved by sharing recent clinical experiences on medical management of SM casualties where there are still important major gaps.

Proposal for Reforming Prehospital Response to Chemical Terrorism Disasters in Japan: Going Back to the Basics of Saving the Lives of the Injured by Securing the Safety of the Rescue Team.

INTRODUCTION: Having experienced the Tokyo subway sarin attack in 1995, Japan has established extremely strict rules on handling injured victims before they are sent to a hospital. As a result, it takes a long time before rescue actions are taken. This report aims to propose a reform to change the system that focuses on saving lives. METHODS: First, the issues in firefighting on sites that currently present problems in Japan were identified. Then, Japanese guidelines were compared with those that were considered in other countries. Based on this, an ideal way of running rescue operations was examined, and a proposal to save many lives was made. This research was conducted with funding from the Ministry of Health, Labour, and Welfare of Japan (MHLW; Chiyoda, Tokyo, Japan). RESULTS: In addition to preventing secondary injuries, the temporal aspect of rescuing people early with the clear goal of saving many lives was emphasized. Priority was given to measures against nerve agents to prevent secondary injuries, which put the rescuers' lives at risk. Possible decontamination methods were pursued before choosing the one that was most appropriate. A linear algorithm was used to determine which decontamination method could be started immediately, and then the gradual use of equipment was recommended. Even if Level A personal protective equipment (PPE) and other dedicated equipment and materials cannot be procured, the possibility of starting rescue activities under certain condition using regular equipment was pointed out. The need for a system for possible victims who would require support, such as foreigners, the handicapped, and elderly people, was also identified. Japan limits the scope of activities that can be undertaken by emergency medical technicians (EMTs) on-site. The way in which on-site medical care can be provided with future legal revisions in mind was also discussed. CONCLUSION: There is an urgent need to build a framework in which rescue activities can take place so that the number of deaths would not rise, even if sarin and other poisons are scattered.

National Institutes of Health (NIH) Executive Meeting Summary: Developing Medical Countermeasures to Rescue Opioid-Induced Respiratory Depression (a Trans-Agency Scientific Meeting)-August 6/7, 2019.

On August 6th, 2019, a two-day trans-agency scientific meeting was convened by the United States (U.S.) National Institute of Allergy and Infectious Diseases (NIAID/NIH) on the research and development of medical countermeasures (MCMs) and treatment strategies to mitigate synthetic opioid-induced toxicities. This trans-agency meeting was an initiative of the Chemical Countermeasures Research Program (CCRP) and organized by the NIAID in collaboration with the National Institute of Drug Abuse (NIDA), the Biomedical Advanced Research and Development Authority (BARDA), the Food and Drug Administration (FDA), and the Defense Threat Reduction Agency (DTRA). The CCRP is part of the larger NIH biodefense research program coordinated by NIAID, which also includes MCM research and development programs against biological, radiological, and nuclear threats. Its overarching goal is to integrate cutting-edge research and technological advances in science and medicine to enhance the nation's medical response capabilities during and after a public health emergency involving the deliberate or accidental release of toxic chemicals. The potential of a mass casualty public health event involving synthetic opioids is a rapidly growing concern. As such, the overall goals of this trans-agency meeting are to better understand opioid-induced toxicities and advance the development of MCMs to mitigate and reverse opioid-induced respiratory depression (OIRD) to prevent consequential mortality. The primary objectives of the meeting were (1) highlight the latest research on mechanisms of OIRD and related toxicities, animal models, diagnostics, delivery technologies, and emerging new treatment options to prevent lethality; (2) identify current knowledge gaps to advance medical countermeasure development; (3) hear from the U.S. FDA on regulatory considerations to support new technology and treatment approaches; and (4) provide a forum for networking and collaborative partnerships. To accomplish this, a diverse group of almost 200 US domestic and international subject matter experts spanning fundamental and translational research from academia, industry, and government came together in-person to share their collective expertise and experience in this important field. This report briefly summarizes the information presented throughout the meeting, which was also webcast live in its entirety to registered remote attendees.

UK resilience to a chemical incident.

Following the deliberate chemical attacks in Salisbury last year, a review of UK resilience to chemical incidence was undertaken. The scope was not limited to deliberate attacks, related to terrorism, but was to include non-deliberate and accidental events. Chemical incidents have wide-reaching consequences irrespective of whether they are deliberate or not. The effects of these incidents manifest themselves in terms of immediate health consequences and will also include economic, political and public health effects that may have a much longer impact than the initial disruption. The economic consequences of the Novichok attack were devastating to the local population and businesses in both the short term and the long term, being felt over a year later. This review discusses the effects of these incidents on infrastructure, healthcare provision, law and order, economics and government at a local, regional and national level. The NHS Emergency Preparedness, Resilience and Response Framework was reviewed, and this provides a basic outline of advice for local government to follow in the case of chemical incidents. However, the wider issues of interdepartmental co-operation and how to maintain a response in the long term require further thought. Moreover, the methods by which interagency and regional resilience is maintained in preparing for such an event require a clearer guideline.

Characterizing Chemical Terrorism Incidents Collected by the Global Terrorism Database, 1970-2015.

BACKGROUND: The Global Terrorism Database (GTD) is an open-source database on terrorist incidents around the world since 1970, and it is maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism (START; College Park, Maryland USA), a US Department of Homeland Security Center of Excellence. The consortium reviews media reports to determine if an event meets eligibility to be categorized as a terrorism incident for entry into the database. OBJECTIVE: The objective of this study was to characterize chemical terrorism incidents reported to the GTD and understand more about the kinds of chemical agents used, the associated morbidity and mortality, the geography of incidents, and the intended targets. METHODS: Chemical terrorism incidents from 1970 through 2015 were analyzed by chemical agent category, injury and fatality, geographic region, and target. RESULTS: During the study period, 156,772 terrorism incidents were reported to the GTD, of which 292 (0.19%) met the inclusion criteria for analysis as a chemical terrorism incident. The reported chemical agent categories were: unknown chemical (30.5%); corrosives (23.3%); tear gas/mace (12.3%); unspecified gas (11.6%); cyanide (8.2%); pesticides (5.5%); metals (6.5%); and nerve gas (2.1%). On average, chemical terrorism incidents resulted in 51 injuries (mean range across agents: 2.5-1,622.0) and seven deaths (mean range across agents: 0.0-224.3) per incident. Nerve gas incidents (2.1%) had the highest mean number of injuries (n = 1,622) and fatalities (n = 224) per incident. The highest number of chemical terrorism incidents occurred in South Asia (29.5%), Western Europe (16.8%), and Middle East/North Africa (13.0%). The most common targets were private citizens (19.5%), of which groups of women (22.8%) were often the specific target. Incidents targeting educational institutions often specifically targeted female students or teachers (58.1%). CONCLUSIONS: Chemical terrorism incidents rarely occur; however, the use of certain chemical terrorism agents, for example nerve gas, can cause large mass-causality events that can kill or injure thousands with a single use. Certain regions of the world had higher frequency of chemical terrorism events overall, and also varied in their frequencies of the specific chemical terrorism agent used. Data suggest that morbidity and mortality vary by chemical category and by region. Results may be helpful in developing and optimizing regional chemical terrorism preparedness activities.

Forensic investigation of incidents involving chemical threat agent: Presentation of the operating procedure developed in Belgium for a field-exercise.

The GIFT CBRN project (Generic Integrated Forensic Toolbox for chemical, biological, radiological and nuclear incidents), funded under the Seventh Framework Programme of the European Commission, has been set up to find solutions for investigating incidents involving CBRN agents. Regarding the forensic point of view, specific tools and procedures to assist forensic investigators to perform a crime scene investigation (CSI) and methodologies to enable the subsequent analysis of the evidences (contaminated with CBRN agents) seized at the crime scene have been developed. To validate the procedures and methods developed within this project and to test them, three field-exercises engaged with one type of agent at the time (i.e. a RN-agent, a B-agent or a C-agent) has been held. The Belgian Defence Laboratories (DLD) in collaboration with Royal Military Academy (RMA) and the National Institute of Criminalistics and Criminology (NICC) has organized the chemical field exercise in Belgium. CSI teams of the Belgian Federal Police (experienced in crime scene investigation, fingerprints and digital forensics but at the time of the exercise not trained to perform their activities in CBRN conditions), SIBCRA teams (experienced in the sampling and identification of CBRN agents in hazardous environments) and the Civil Protection (experienced in entering zones with potential chemical hazards in full individual protective equipment) were involved. Since those teams never worked together in CBRN conditions, the exercise was used to establish the first operating procedure for CSI and laboratory analysis for CBRN and forensic materials in Belgium. The main steps of the procedure applied during this filed-exercise are described is this manuscript. The first step was the reconnaissance performed to (i) identify/quantify the threat agent involved, (ii) to document the scene and (iii) to collect priority forensic evidences. The second step focused on the collection of other forensic evidences, the sampling of DNA traces and the revelation of fingerprints at the scene. The collection of CBRN agents was performed during step 3. Step 4 concentrated on the decontamination and transport of evidences and traces sampled in the contaminated zone. The revelation of fingerprints in a glovebox (step 5) was finally demonstrated. In conclusion, this field-exercise was an opportunity for the different Belgium services to work together, to learn from each other, and to work towards the establishment of a national operating procedure to manage investigations in CBRN conditions.

[Analysis of Countermeasures against Chemical Terrorism].

As a countermeasure against terrorism involving highly toxic chemical warfare agents, the rapid identification of the causative toxic substances is extremely important. This symposium review describes analytical methods the author's group has developed for detecting nerve gases after either high level or low level exposure. As a method for assessing human exposure to high levels of nerve gases, a technology that detects nerve gas hydrolysis products, i.e., strong anion exchange extraction-tert-butyldimethylsilyl derivatization-selectable one-dimensional or two-dimensional GC-MS, is explained. As a method for assessing human exposure to low levels of nerve gases, two technologies that detect adducts of nerve gas with blood cholinesterase, i.e., adduct purification-enzymatic digestion-LC/MS and fluoride-mediated regeneration-solid phase extraction-large volume introduction GC-MS, are explained.

Victims of chemical terrorism, a family of four who were exposed to sulfur mustard.

Sulfur mustard (SM) was responsible for more than 80% of all documented chemical casualties during the Great War. Recent literature on clinic picture of SM exposure remained so limited with the sporadic cases who were accidentally exposed to SM especially either in Western Europe or China. We reported a Syrian family of four who became victims of chemical terrorism due to SM exposure and we described the detailed clinical course of the family including the medical history, initial symptomatology, clinical examination, hematological data, and initial treatment in the first 48 hours after exposure at Kilis State Hospital, Turkey. The principles of our therapeutic approaches were designed according to the total affected body surface area, severity of cutaneous and respiratory lesions, and existing hematological disorders. SM is still considered as a critical vesicant agent and a current threat because of its ease of synthesis. Chemical terrorist attacks of non-state actors or terrorist organizations with "home-made" SM is likely such a threat which is targeting health systems of developed and developing countries. Except sarin attacks in Japan, the literature depends on real incidents of chemical terrorism is so rare and for this reason we have gaps and challanges in the prepardness of medical response system against chemical terrorism. Medical management could be performed adequetly only if the response system is well planned, well equipped, and well prepared for overburdened medical facilities filled with SM contaminated casualties after a chemical terrorist attack.