Emergency Preparedness and Response in Israel During the Gulf War,☆☆,,★★

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Abstract

We examined the effect of the emergency response on medical and public health problems during the 1991 Gulf War in Israel. On the first day of the conflict, the number of deaths from suffocation, asphyxiation, aspiration, myocardial infarction, cardiac arrest, and cerebrovascular accident increasd abruptly, as did the number of sudden deaths associated with the use of tight-fitting masks with filters in sealed rooms. Much of the excess risk for death from cardiorespiratory complications during the first alert may have been a consequence of its duration (140 minutes). Mass evacuation and concrete buildings are believed to have kept the death toll from trauma down, and mask use may have protected against facial and upper-airway injuries. Falls and hip fractures, airway irritation from exposure to bleach, carbon monoxide intoxication from open kerosene heaters in sealed rooms, and self-injection with atropine syringes were also noted. A measles epidemic and increased death rates from automobile crashes were other preventable causes of death. Protection against biological warfare was limited to surveillance of trends for pneumonia and gastroenteritis. Emergency planners failed to anticipate the need for better mask fit, hands-on training in the use of masks, and special guidelines for older persons to prevent deaths from suffocation and other cardiovascular-respiratory problems in the first minutes of use. If masks are to be distributed as a protection against chemical warfare, a simpler model including the use of shrouds for whole-body skin protection might help avoid cardiorespiratory complications. Public health problems not adequately dealt with in the predisaster period are apt to emerge with greater severity during a crisis.

[Barach P, Rivkind A, Israeli A, Berdugo M, Richter ED: Emergency preparedness and response in Israel during the Gulf War. Ann Emerg Med August 1998;32:224-233.]

Section snippets

INTRODUCTION

Chemical warfare was banned by the 1924 Geneva Protocol on Chemical Weapons as a result of its horrific effects on soldiers on the battlefield in World War I. This ban was reaffirmed during the 1989 Conference on the Prohibition of Chemical Weapons after the Iran-Iraq War, when chemical warfare was directed against both soldiers and civilians.1 But until the Gulf War, there had been no nationwide experience with the medical complications associated with virtually populationwide mask use and

DATA ANALYSIS

We obtained data on date, age, sex, and war-related cause of death for all persons whose families were compensated by the National Insurance Institute (NII) and population census data from the Central Bureau of Statistics. The demographic data became available in 1993. Information on missile alerts is based on material from a workshop2 and data from cited sources. We tabulated death trends in terms of relevant time, person, and outcome variables and analyzed death risks from cardiorespiratory

SAFETY MEASURES

In response to public pressure, more than 4 million individuals received sealed kits between October and December 1990 containing full face-fitting rubber masks with detachable canisters containing activated, impregnated charcoal filter cartridges. The cartridge is screwed into place just before use, but a cap and plastic plug must be removed beforehand. Atropine syringes were also supplied. The public was instructed not to open the kits or remove the cartridge cover before the announcement of

Mask-related morbidity and mortality from cardiorespiratory complications

Between 36 and 40 missiles were reported to have hit Israel, on 18 separate occasions during the 47-day war. The total missile alert time was 730 minutes. The first missile alert lasted 140 minutes; all subsequent alerts lasted 12 to 52 minutes. By 1993, the Israel NII and the Ministry of Defense4 certified 119 deaths, including 2 from traumatic injuries, in a population of some 4.9 million5 as directly related to missile alerts and hits, mask use, and confinement in sealed rooms. This toll is

Respiratory and enteric disease

Reports of Iraq’s use of biologic-warfare agents, including typhus and cholera-producing organisms,22 were noted by the Health Ministry. Daily district-by-district epidemiologic surveillance for infectious disease (respiratory and enteric) carried out by the ministry indicated no increase in either during the war.20 Later reports indicated that aerosols containing anthrax, Clostridium botulinum toxin, bubonic plague, and cholera (and, possibly, DNA-recombinant viruses) were potential threats.23

MOTOR VEHICLE CRASHES

Deaths and injuries resulting from road crashes were the main cause of traumatic death and injury during missile attacks. During the 47 days of the emergency, 2,340 people were injured and 31 killed among vehicle occupants; 474 total casualties and 14 deaths were reported among pedestrians. Compared with the same period in 1990, there was a total decrease of some 22% to 23% in total casualties among occupants and pedestrians but a selective increase in the number of deaths among occupants

PREVENTIVE LESSONS: MASK AND INJURY HAZARDS AND RISKS, TRAINING, AND INDIVIDUAL AND COMMUNITY RESPONSE

Emergency planners failed to anticipate the complications from populationwide use and misuse of masks, especially of the passive-filter type, in high-risk subgroups who did not receive hands-on training. Training has been shown to be particularly effective in improving compliance with respiratory protective devices by reducing hyperventilation and other symptoms such as shortness of breath, dizziness, blurred vision, paresthesia, trembling, convulsions, and alertness,30, 31, 32 as acknowledged

FAILURES IN THE PRECRISIS PHASE OF EMERGENCY RESPONSE

Would it have been possible to prevent the deaths from suffocation and cardiorespiratory complications seen particularly in the initial alerts and missile attacks? “Hands-on,” customized training and education and custom-fitting of masks for civilians, notably persons at high risk, were not carried out, and the public was instructed to keep kits closed. But among schoolchildren, many of whom did receive such hands-on training, there were no reported deaths resulting from mask use. The first

CONCLUSION

In this emergency, the death toll resulting from cardiorespiratory complications and sudden death caused by mask use and misuse, anxiety, stress, and confinement to sealed rooms greatly exceeded that of trauma caused by missile attacks. This outcome broadcasts a precautionary message to those responsible for deciding whether predisaster mass education and distribution of full-face masks with filters is a justified measure for people living near high-risk sites for toxic leaks or drift.

ADDENDUM

As the Iraqi threat looms again, and while chemical and biological weapons are again being directed offensively at Israel, Israel is in the position to apply many of the lessons and missteps from the Gulf War crisis, alluded to in this article. As Operation Desert Thunder is winding down from a climatic high, it is also time to reflect on what we know about Saddm Hussein’s chemical and biological capabilities. After 7 years of combing Iraq for hidden weapons, inspectors for the United Nations

Acknowledgements

We acknowledge the help of the Conanima Foundation (Switzerland), Econet (Israel), and Dr James Komberg, Dr Charles Greenblatt, and Dr Jakob Adler (Israel).

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      Hundreds were treated for acute anxiety, unnecessary atropine injections, and other complications. The Gulf War showed that, “Public health problems not adequately dealt with in the pre-disaster period are apt to emerge with greater severity during a crisis” [16]. Emergency planners preparing for the Gulf War failed to anticipate the complications from wide distribution of protective measures and misuse of masks [17].

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    From the Department of Anesthesiology, and Critical Care, Massachusetts General Hospital, Boston, MA.*and the Department of Surgery and School of Public Health§ and Community Medicine (Unit of Occupational and Environmental Medicine–Disaster Medicine Section), Hebrew University–Hadassah Medical Center, Jerusalem, Israel.

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    Editor's Note: An incorrect version of this article was published in the October 1997 issue of Annals. The corrected article is reprinted here in its entirety.

    Reprint no. 47/1/89462

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    Address for reprints: Paul Barach, MD, MPHD Department of Anesthesia Massachusetts General Hospital Harvard Medical School Boston, MA 02114

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