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The disproportionate morbidity and mortality associated with chemical weapons led to the development of the Geneva Protocol (1925) for the prohibition of the use in war of asphyxiating, poisonous, or other gases and the Chemical Weapons Convention (1997), banning the stockpiling and use of these weapons. 1,2 Despite international support to ban the stockpiling and proliferation of chemical weapons, recent history has demonstrated their continued use, particularly in Syria and Iraq. 2-5 A study from 2018 found that from March 2011 to April 2017, at least 1206 individuals in nongovernment-controlled areas of Syria died in chemical weapons attacks, with 97.6% of those killed identified as civilians. 6 While chemical attacks account for a small portion of the total global casualties attributed to terrorism, the use of chemical agents has unique and long-term physical and mental health consequences among victims and health care workers. 6-9 Additionally, clinicians practicing in conflict zones frequently encounter ethical and medical challenges in managing individuals who may be exposed to chemical weapons. 10 Chemical weapons preparedness has clear relevance for individuals practicing in conflict zones, as well as among emergency responders. Additionally, isolated chemical attacks perpetuated by state agents are a growing concern, as highlighted by recent nerve agent attacks in Kuala Lumpur and Salisbury, UK. 11,12
There are limited data analyses to inform the prioritization of chemical weapons preparedness resources by policy-makers, clinicians, and first responders. In the setting of declining federal funding for chemical and other nonconventional weapons preparedness, there is a growing need to better understand the agents now being used, the targets, and routes of exposure to direct funding, training, and pre-deployment of proper equipment. 13 Understanding the trends in chemical terror attacks may be useful to inform the specification of medical education curricula and continuing training for first responders, clinicians, and hospitals to prepare for potentially devastating chemical terror attacks.
Our objective was to describe the epidemiology of global chemical terror events over the past 5 decades with an emphasis on recent global conflict settings to inform future priorities for training of civilian public safety professionals in the management of exposure to chemical weapons.
METHODS
We conducted a descriptive retrospective review of chemical agent terror attacks to understand historical trends in agents, targets, and routes of...