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STATISTICAL VIEWS ON
LATE COMPLICATIONS OF CHEMICAL WEAPONS ON IRANIAN CW VICTIMS
Shahriar Khateri M.D.
Organization of Veterans' Affairs (Janbazan org.) Health and Treatment
Department
Dastgerdi Ave.-Kowsar Building.TEHRAN-IRAN
SUMMARY
During the 8
years Iran - Iraq war (1980 - 1988) chemical weapons had been frequently
used by Iraqi army against the Iranian military personnel[1] and against
the civilian population of Iranian border towns and villages[2-10].
During these chemical attacks, several kinds of chemical agents (nerve
agents, blistering agents, mixed agents) were used[11].
According
to the recorded data from field emergency units, field hospitals in
the battle zones and the list of evacuated CW victims from the front,
more then 100,000 military and civilian personnel had received treatment
for the acute effects of CW agents in those medical centers and in other
hospitals and cities behind the front (both in- and out-patient treatment).
Today, more than 13 years after the end of the Iraq - Iran war, approximately
34,000 Iranian military and civilians are still suffering from the long
term effects of chemical weapons deployed by Iraq (especially mustard
gas), and they are receiving medical treatment services by the organization
of Veterans' Affair, the Janbazan organization(12).
The severity
of these late complications in CW victims depends on the rate of exposure,
type and dose of CW agents[13], so we have a method in the Janbazan
organization for categorizing the severity of complications in the CW
victims. According to this method (based on severity of late complications
and the clinical status), there are three categories of patients: patients
with mild, moderate and severe complications. In this article the criteria
used in this categorizing method and the statistical results of this
categorizing are discussed.
- INTRODUCTION
A brief
history of chemical warfare to include the use of CW by Iraq during
the Gulf War: The use of poisons as weapons and efforts to ban them
dates from ancient times. Despite the Hague convention (1899/1907)
and Geneva protocol (1925), chemical weapons were used in World War
(WW)1, the Iran-Iraq war, by Italy in Ethiopia, by Japan in China
and various other conflicts, and, today they still remain a serious
threat for civilian and military personnel.
During
the Iran-Iraq war (1980-1988) there were, initially, many unconfirmed
reports that Iraq had been using chemical weapons, but the international
community was slow to react. However, UN fact-finding teams did confirm
that Iraq had indeed been using chemical weapons on a massive scale
and that Iran had suffered thousands of military and civilian casualties
as a result of these attacks[14].
The first
UN mission came to Iran in March of 1984 and released its official
report (No: S/16433). They returned to Iran in 1986 and released their
second report (No: S/17911) and the third mission took place on 1987
and the third report released in May 1987(No: S/18852)[15].
The conclusions,
based on field inspections, clinical examinations of casualties and
laboratory analyses of chemical ammunition, can be summarized as follows:
- a. chemical weapons, in the form of aerial bombs, had been
used in the areas inspected in Iran by the official UN team,
- b. the main type of chemical agent used was bis-sulfide or
mustard gas,
- c. and on some occasions evidence was found for the use of
the nerve agent ethyl N, N-dimethylphosphor amidio cyanidate, or tabun[16].
These reports renewed attention to the dangers of chemical weapons
proliferation and to the horrors of chemical warfare[17].
THE CATEGORIZING METHOD
Today, more
than 13 years after the end of the Iraq-Iran war, approximately 34,000
Iranian military and civilian people are still suffering from the long
term effects of chemical weapons (especially sulfur mustard) used by
Iraq, and they are receiving medical treatment by the organization of
veterans affair (Janbazan org). The severity of these late complications
in those chemical warfare victims (CWV) depends on the rate of exposure
to chemical agents and the type and dose of agents. We have developed
a method for categorizing the severity of complications in these CWV.
According to this method there are three categories of patients with
chronic effects: mild, moderate and severe complications. The treatment
and rehabilitation services and also the disability are based on the
result of this categorizing method, so the criteria for this method
for each category has been discussed in several professional and scientific
committees and evaluated by the results of other researchers in this
field. The method is compatible with scientific resources and textbooks
and is principally based on physical examination, laboratory and paraclinic
findings and the clinical status of patients. In order to avoid any
misinterpretation in the paraclinic findings and discrepancies in evaluating
physical examination findings, there is a standardized instruction,
which is the basis of our clinics' performance.
PRINCIPLES OF THE CATEGORIZING METHOD
DETERMINING OF SEVERITY IN PULMONARY SYSTEM LESIONS:
a. Mild
lesions: spirometry: 65 =<80 or 65 =<80
physical exam : abnormal lung sounds
b. Moderate
lesions: spirometry: 50 =<65 or 50 =<65
physical exam : abnormal lung sounds
c. Severe
lesions: spirometry: 40 =<50 or 40 =<50
physical exam: abnormal lung sounds probably with scianosis and intercostal
retraction or tracheal stenosis in bronchoscopy
DETERMINING OF SEVERITY IN SKIN LESIONS:
a. Mild lesions:
1) Itching
or burning without clinical lesions
2)
Dry skin .
3)
Hypo or hyper pigmentation or both or depigmentation less than 18% of
body surface or in covered area.
4)
Alopecia areata totalis or universalis.
5)
Generalized vitiligo.
6)
Psoriasis (less than 20% of body surface).
7)
Lichen simplex and limited prurigo.
8)
Limited and mild eczema.
9)
Limited scars in covered area .
10) Single
keloid without limitation in rang of motion and in covered area.
11) Severe
acne vulgaris and nodulous or suppurative hidradenitis.
12) Chronic
hives or angioedema.
13) Vesicant
lesions (localized).
14) Recurrent
superficial fungal disease (chronic resistant dermatophitosis).
b. Moderate lesions:
1) Hypo
or hyper pigmentation or both or depigmentation of more than 18% of
body surface or in uncovered area.
2) Severe
and diffuse eczema.
3) Generalized
prurigo.
4) Diffuse
scare ( or in uncovered area ).
5) Keloid
with limitation in range of motion and in uncovered area.
6) Generalized
recurrent vesicant lesions.
7) Generalized
and chronic itching with clinical lesions
8) Psoriasis(more
than 20% of body surface).
9) BCC
c. Severe lesions:
1) skin
or mucosal cancer (except BCC)
DETERMINING OF SEVERITY IN EYE LESIONS:
- a. Mild lesions:
- (Complaints) photophobia- foreign body sensation- tearing- burning-
itching - red eye - blurred vision - visual loss - pain - problem
in reading (signs) conjunctival inflammation and hyperemia - sub conj.
hemorrhage - vessels swelling - blepharitis - Meibomian glands dysfunction
- papillary change
- b. Moderate lesions:
- Above complications + mild corneal involvement: epithelial and sub
epithelial opacity - anterior stroma in peripheral cornea - perilimbal
hyper pigmentation - iron deposit in cornea - band keratopathy - pannus<2mm
- no melting - BUT : 5-10 sec -Schirmer(with anesthesia) : 5-10 mm
- red reflex : 9/10 - 10/10
- c. Severe lesions:
- Above complications + severe corneal involvement: Thinning - melting
- severe hyaline like deposit - corneal vascularization, BUT <5
sec - Schirmer (with anesthesia)<5 mm - red reflex: 1/10-4/10
- d. Very severe:
- - above complication AND very severe corneal involvement: Diffuse
corneal opacity - severe thinning - dermatocel - severe vascularization
- red reflex<1/10 - retina is not visible
CONCLUSIONS
Chemical
weapons have a broad spectrum of harmful damage on different human organs.
According to the results of our evaluations on the clinical status of
Iranian CWVs, and the categorizing the severity of late complications
in them (Table 1), the most common complications in these patients are
the pulmonary complications (from mild lesions to severe lesions). In
general about 42.5 percent of Iranian CWV population are suffering from
pulmonary complications (37% mild lesions - 4.5% moderate lesions -
1% severe lesions) (Graph 1). On the other hand as the nature of pulmonary
complications of mustard gas is progressive and some late complications
appear many years after exposure, the number of patients with these
complications will rise. Graphs 2 and 3 show the percent of complications
to the eye and skin. Managing this large number of patients with different
complications (mostly with mixed complications) is impossible without
a well-organized care system. So in our country there are now several
special clinics and well equipped medical centers for observing these
patients, as well as a standard medical care program for management
of late complications in these patients (by the periodical visits and
follow up of patients).
REFERENCES:
- UN documents/17911 op.cit
- UN documents/18809 April 16 1987
- UN documents/18825 April 27 1987
- UN documents/18852 may 8 1987
- UN documents/18866 may 15 1987
- UN documents/18953 jun 29 1987
- UN documents/18956 jun 30 1987
- UN documents/18966 jul 6 1987
- UN documents/18967 jul 7 1987
- UN documents/19006 jul 30 1987
- UN document /19823 April 25 1988
- Annual statistical report booklet - clinical status of CW victims
- Janbazan organization (veterans affair) - Health and Treatment Department
- Oct 2000.
- H. Marquardt - S.G. Schafer - R. Mcclellan-F. Welsch (1999) - TOXICOLOGY
- Academic press - chapter 35
- UN security council resolution 612 (1988)
- UN documets s/16443 - s/17911 - s/ 18852
- UN document s/19823 april 1988
- Jan L. Willems - clinical management of mustard gas casualties -
Royal school of the medical services Leopold's Kazerne - Ghent, Belgium
- chapter 1-2
TABLES AND FIGURES
TABLE 1: results of categorizing the late complications (severity
of lesions)
GRAPH 1: lung lesions
GRAPH 2: eye lesions
GRAPH 3: skin lesions
01-4, issue no. 85
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