David A. Jett

A comprehensive evaluation of the efficacy of leading oxime therapies in guinea pigs exposed to organophosphorus chemical warfare agents or pesticides.

The currently fielded pre-hospital therapeutic regimen for the treatment of organophosphorus (OP) poisoning in the United States (U.S.) is the administration of atropine in combination with an oxime antidote (2-PAM Cl) to reactivate inhibited acetylcholinesterase (AChE). Depending on clinical symptoms, an anticonvulsant, e.g., diazepam, may also be administered. Unfortunately, 2-PAM Cl does not offer sufficient protection across the range of OP threat agents, and there is some question as to whether it is the most effective oxime compound available. The objective of the present study is to identify an oxime antidote, under standardized and comparable conditions, that offers protection at the FDA approved human equivalent dose (HED) of 2-PAM Cl against tabun (GA), sarin (GB), soman (GD), cyclosarin (GF), and VX, and the pesticides paraoxon, chlorpyrifos oxon, and phorate oxon. Male Hartley guinea pigs were subcutaneously challenged with a lethal level of OP and treated at approximately 1 min post challenge with atropine followed by equimolar oxime therapy (2-PAM Cl, HI-6 DMS, obidoxime Cl₂, TMB-4, MMB4-DMS, HLö-7 DMS, MINA, and RS194B) or therapeutic-index (TI) level therapy (HI-6 DMS, MMB4-DMS, MINA, and RS194B). Clinical signs of toxicity were observed for 24 h post challenge and blood cholinesterase [AChE and butyrylcholinesterase (BChE)] activity was analyzed utilizing a modified Ellmans method. When the oxime is standardized against the HED of 2-PAM Cl for guinea pigs, the evidence from clinical observations, lethality, quality of life (QOL) scores, and cholinesterase reactivation rates across all OPs indicated that MMB4 DMS and HLö-7 DMS were the two most consistently efficacious oximes.

The CounterACT Research Network: Basic Mechanisms and Practical Applications

The National Institutes of Health has developed a comprehensive research program that includes research centers of excellence, individual research projects, small business projects, contracts, and interagency agreements to conduct basic, translational, and clinical research aimed at the discovery and/or identification of better medical countermeasures against chemical threat agents. Chemical threats include chemical warfare agents, toxic industrial and agricultural chemicals, and toxins and other chemicals that could be used intentionally as an act of terror or by large-scale accidents or natural disasters. The overarching goal of this research program is to enhance our medical response capabilities during an emergency. The program is named Countermeasures Against Chemical Threats (CounterACT). It supports translational research, applying ideas, insights, and discoveries generated through basic scientific inquiry to the treatment or prevention of mortality and morbidity caused by chemical threat agents. The categories of research supported under this program include creation and development of screening assays and animal models for therapy development, identification of candidate therapeutics, obtaining preliminary proof-of-principle data on the efficacy of candidate therapeutics, advanced efficacy and preclinical safety studies with appropriate animal models using Good Laboratory Practices (GLP), and clinical studies, including clinical trials with new drugs. Special consideration is given to research relevant to people who are particularly vulnerable, including the young, the elderly, and individuals with pre-existing medical conditions.

Chemical toxins that cause seizures

Seizurogenic chemicals include a variety of toxic agents, including chemical warfare agents, toxic industrial chemicals, and natural toxins. Chemical weapons such as sarin and VX, and pesticides such as parathion and carbaryl cause hyperstimulation of cholinergic receptors and an increase in excitatory neurotransmission. Glutamatergic hyperstimulation can occur after exposure to excitatory amino acid toxins such as the marine toxin domoic acid. Other pesticides such as lindane and strychnine do not affect excitatory neurotransmission directly, but rather, they block the inhibitory regulation of neurotransmission by antagonism of inhibitory GABA and glycine synapses. In this paper, chemicals that cause seizures by a variety of molecular mechanisms and pathways are discussed.

Neurological aspects of chemical terrorism

This review describes the neurological aspects of chemical terrorism with a focus on the civilian perspective. This review defines chemical threats as highly toxic chemicals that could be used in a terrorist attack, or those that could be released at toxic levels from transportation vehicles and storage facilities during an accident or natural disaster. Chemical threats can be categorized based on the target tissues and types of primary acute effects they produce (Table). Probably the most easily recognizable chemical terrorism threats are the traditional chemical warfare agents (CWAs) developed during the first and second World Wars. These include the organophosphorus (OP) nerve agents, such as sarin and VX, and the mustard blister agents. As a consequence of previous state-sponsored CWA programs, several stockpiles remain around the world. Sulfur mustard and OP nerve agents were used against Iraqi Kurdish villages in the late 1980s, and more recently, the OP nerve agents were used by the Japanese cult organization Aum Shinrikyo in two separate attacks against civilians in Japan. The United States also produces and uses more than 80,000 chemicals, many of which are highly toxic and lethal at relatively low doses. Chemical agents in this broad category include the toxic industrial chemicals (TICs) manufactured and stored in large volume at industrial facilities and transported across the nation for various uses. Whereas the threat from CWAs is mitigated by restricted access, difficulty in synthesis of purified agent, and international treaties against their use, the TICs are not regulated as strictly, and many chemicals are readily available or stored in large enough amounts to pose a serious threat to human health if released by accident, natural disaster, or a deliberate act of terror. One of the most deadly industrial accidents occurred in Bhopal, India, where methyl isocyanate was released from an industrial storage tank killing 5,000 people and injuring thousands more, some with long-term effects. More recent fatal accidents involving large-scale chlorine gas releases during transportation in the United States have brought national attention to the hazards associated with TICs. Organophosphorus Nerve Agents The OP nerve agents belong to a chemically diverse group of organic compounds that have in common at least one carbon atom bound to a phosphorous atom. They are sometimes referred to as nerve gases because of the high volatility of some of the specific agents, but in fact, they are clear, colorless liquids at room temperature. The OP nerve agents were derived from OP pesticides during World Ward II by the Nazis to be used as CWAs against the allied forces. Traditional OP nerve agents fall into two groups, the Gand the V-series, based on their chemical and physical properties. The G-series nerve agents (GA, tabun; GB, sarin; GD, soman; and others) are volatile liquids at room temperature that can be deadly when inhaled as a vapor or from percutaneous exposure to the vapor. V-series agents (VX and others) have a consistency similar to oil and do not evaporate rapidly. V-series agents can remain on clothing and other surfaces for a long time, and they pose a greater risk from dermal exposure or by ingestion. Agents in the V-series are approximately 10to 100-fold more toxic than those in the G-series. OP nerve agents inhibit the catalytic function of acetylcholinesterase (EC 3.1.1.7; AChE) by phosphorylating the esteratic site of the enzyme. This removes the capacity of the enzyme to catalyze its endogenous substrate acetylcholine (ACh). As a consequence, the hydrolysis of ACh is prevented, leading to accumulation of ACh in the synaptic cleft and overstimulation and subsequent desensitization of muscarinic and nicotinic ACh receptors at cholinergic synapses in the brain, glands, and skeletal and smooth muscles. The OP nerve agents are more toxic than the related OP pesticides still in use today, and they bind irreversibly to AChE and interact at several other molecular sites at low doses. They are lethal at minute doses. For example, the median lethal dose (LD50) of VX for a 70kg person is only 10mg. The acute effects of OP nerve agents and pesticides are well characterized and include a progression from miosis, excessive secretions, and muscle fasciculation to epileptic seizures, muscle

Neurotoxic Pesticides and Neurologic Effects

Pesticides represent one of the largest classes of toxic chemicals produced, stored, and used in the United States and abroad. These chemicals are designed to be toxic and many, besides being toxic to the pests they are intended to control, are also toxic to nontarget species including humans. The article gives a brief review of their toxicity to humans with emphasis on their effects on the nervous system. Examples of case studies are included to illustrate their toxicity. A discussion of the possible contribution of occupational and other pesticide exposures to neurologic diseases and disorders is also included.

The NIH Countermeasures Against Chemical Threats Program: overview and special challenges.

Intentional exposures to toxic chemicals can stem from terrorist attacks, such as the release of sarin in the Tokyo subway system in 1995, as well as from toxic industrial accidents that are much more common. Developing effective medical interventions is a critical component of the overall strategy to overcome the challenges of chemical emergencies. These challenges include the rapid and lethal mode of action of many toxic chemicals that require equally fast‐acting therapies, the large number of chemicals that are considered threats, and the diverse demographics and vulnerabilities of those who may be affected. In addition, there may be long‐term deleterious effects in survivors of a chemical exposure. Several U.S. federal agencies are invested in efforts to improve preparedness and response capabilities during and after chemical emergencies. For example, the National Institutes of Health (NIH) Countermeasures Against Chemical Threats (CounterACT) Program supports investigators who are developing therapeutics to reduce mortality and morbidity from chemical exposures. The program awards grants to individual laboratories and includes contract resource facilities and interagency agreements with Department of Defense laboratories. The range of high‐quality research within the NIH CounterACT Program network is discussed.

Toxicity and median effective doses of oxime therapies against percutaneous organophosphorus pesticide and nerve agent challenges in the Hartley guinea pig

Anticholinesterases, such as organophosphorus pesticides and warfare nerve agents, present a significant health threat. Onset of symptoms after exposure can be rapid, requiring quick-acting, efficacious therapy to mitigate the effects. The goal of the current study was to identify the safest antidote with the highest therapeutic index (TI = oxime 24-hr LD50/oxime ED50) from a panel of four oximes deemed most efficacious in a previous study. The oximes tested were pralidoxime chloride (2-PAM Cl), MMB4 DMS, HLö-7 DMS, and obidoxime Cl2. The 24-hr median lethal dose (LD50) for the four by intramuscular (IM) injection and the median effective dose (ED50) were determined. In the ED50 study, male guinea pigs clipped of hair received 2x LD50 topical challenges of undiluted Russian VX (VR), VX, or phorate oxon (PHO) and, at the onset of cholinergic signs, IM therapy of atropine (0.4 mg/kg) and varying levels of oxime. Survival was assessed at 3 hr after onset clinical signs. The 3-hr 90th percentile dose (ED90) for each oxime was compared to the guinea pig pre-hospital human-equivalent dose of 2-PAM Cl, 149 µmol/kg. The TI was calculated for each OP/oxime combination. Against VR, MMB4 DMS had a higher TI than HLö-7 DMS, whereas 2-PAM Cl and obidoxime Cl2 were ineffective. Against VX, MMB4 DMS > HLö-7 DMS > 2-PAM Cl > obidoxime Cl2. Against PHO, all performed better than 2-PAM Cl. MMB4 DMS was the most effective oxime as it was the only oxime with ED90 < 149 µmol/kg against all three topical OPs tested.

Synthesis and Storage Stability of Diisopropylfluorophosphate

Diisopropylfluorophosphate (DFP) is a potent acetylcholinesterase inhibitor commonly used in toxicological studies as an organophosphorus nerve agent surrogate. However, LD50 values for DFP in the same species can differ widely even within the same laboratory, possibly due to the use of degraded DFP. The objectives here were to identify an efficient synthesis route for high purity DFP and assess the storage stability of both the in-house synthesized and commercial source of DFP at the manufacturer-recommended storage temperature of 4°C, as well as −10°C and −80°C. After 393 days, the commercial DFP stored at 4°C experienced significant degradation, while only minor degradation was observed at −10°C and none was observed at −80°C. DFP prepared using the newly identified synthesis route was significantly more stable, exhibiting only minor degradation at 4°C and none at −10°C or −80°C. The major degradation product was the monoacid derivative diisopropylphosphate, formed via hydrolysis of DFP. It was also found that storing DFP in glass containers may accelerate the degradation process by generating water in situ as hydrolytically generated hydrofluoric acid attacks the silica in the glass. Based on the results here, it is recommended that DFP be stored at or below −10°C, preferably in air-tight, nonglass containers.

Efficacy of Recommended Prehospital Human Equivalent Doses of Atropine and Pralidoxime Against the Toxic Effects of Carbamate Poisoning in the Hartley Guinea Pig.

Purpose: Aldicarb and methomyl are carbamate pesticides commonly implicated in human poisonings. The primary toxic mechanism of action for carbamate poisoning is cholinesterase (ChE) inhibition. As such, it is logical to assume that the currently accepted therapies for organophosphate poisoning (muscarinic antagonist atropine and the oxime acetylcholinesterase reactivator pralidoxime chloride [2-PAM Cl]) could afford therapeutic protection. However, oximes have been shown to be contraindicated for poisoning by some carbamates. Methods: A protective ratio study was conducted in guinea pigs to evaluate the efficacy of atropine and 2-PAM Cl. The ChE activity was determined in both the blood and the cerebral cortex. Results: Coadministration of atropine free base (0.4 mg/kg) and 2-PAM Cl (25.7 mg/kg) demonstrated protective ratios of 2 and 3 against aldicarb and methomyl, respectively, relative to saline. The data reported here show that this protection was primarily mediated by the action of atropine. The reactivator 2-PAM Cl had neither positive nor negative effects on survival. Both blood acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activities were significantly reduced at 15 minutes postchallenge but gradually returned to normal within 24 hours. Analysis of cerebral cortex showed that BChE, but not AChE, activity was reduced in animals that succumbed prior to 24 hours after challenge. Conclusion: The results suggest that coadministration of atropine and 2-PAM Cl at the currently recommended human equivalent doses for use in the prehospital setting to treat organophosphorus nerve agent and pesticide poisoning would likely also be effective against aldicarb or methomyl poisoning.

A screening tool to prioritize public health risk associated with accidental or deliberate release of chemicals into the atmosphere

The Chemical Events Working Group of the Global Health Security Initiative has developed a flexible screening tool for chemicals that present a risk when accidentally or deliberately released into the atmosphere. The tool is generic, semi-quantitative, independent of site, situation and scenario, encompasses all chemical hazards (toxicity, flammability and reactivity), and can be easily and quickly implemented by non-subject matter experts using freely available, authoritative information. Public health practitioners and planners can use the screening tool to assist them in directing their activities in each of the five stages of the disaster management cycle.