Qandil short field manual for five chemical and biological agents.

Awareness, protection, decontamination,treatment.
This manual is intended for paramedical personnel and it is limited to awareness, prevention and treatment with locally and presently available means, of five possible chemical and biological agents in North Iraqi Kurdistan. It is not intended to face military medical circumstances, nor military defense operations. It is for paramedical teams assisting small number of civilian population some time after the eventuality of an attack, giving them first aid treatment, referring and /or transferring them to hospital.
Decontamination procedure, prophylaxis and treatment are given keeping in mind what is conceivably available and feasible at the present in the area. The best high standard method of dealing with some of the issues is given for cultural and awareness reasons only since it is not presently available. Such is the case, for instance, of the anthrax vaccination, which is not available, or the uses of oximes for nerve agents which are also not available, just as preventive assumption of carbamate pyridostigmine which is also not available, and so on.
The armamentarium is what is available, lots of water, water and soap, hypochlorite solution, baby shampoo, saline solution, Atropine injection. Atropine and antibiotic eye ointment, diazepam, for "gas" attacks. Ciprofloxacin and doxycyclin (only oral) for anthrax. The lack of toxoid vaccine and equine serum antitoxin against Botulinum toxins it is compelling to describe Clostridium Botulinum toxins attack only as an awareness to limit its damage. Knowledge and awareness is a powerful defense in these circumstances.
The five agents are Anthrax spores, Botulinum toxins, Mustard agent, Lewisite, and nerve agents. Though Mustard and nerve agents are often referred as gas, they are really liquid which would be spread as aerosol on explosion of the vector, a shell or a rocket, and they will behave like a gas only for a short time because they will eventually fall on the ground. All this is of some importance because a simple defense would be, under attack, to avoid the area contaminated by these aerosol for the few hours in which they will behave like gas. The same is true for anthrax spores and botulinum toxins in case they should be spread in the air.
It is well known that gas masks given to an entire population have more a psychological reassurance benefit rather than offering real protection against the so called "gas". Mustard, Lewisite and nerve agents (Tabun Sarin Soman and Vx) do penetrate through the skin and protection is given only by full gear total body suit with hood and overboots. This is possible, worldwide, only for special military decontamination unit. Again awareness and simple measure are not only commendable but perhaps in some circumstances more useful. In fact masks alone to untrained people, by giving a false sense of security, could be lethal.
Health team leaders should assure the availability of plenty of water where decontamination procedure will possibly be carried out. They should also assure to have plenty of plastic bags to dispose of contaminated items, and fresh clothing or pajamas or both to re dress the decontaminated individuals.

Giorgio G. Francia, MD
Specialist Surgeon
Qandil Senior Consultant in Trauma and War Surgery
Relief International Head of Mission
Erbil and Sulaymany, February 2003
Translated in to Kurdish Language by

Printing of this manual was funded by Qandil, Relief International, and Kurdish Medical Program
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