Nervni Otrov VX
Nervni Otrov VX
Nervni Otrov VX
IOM-2794-04-001
The National Academies
HEALTH EFFECTS OF
PROJECT SHAD
CHEMICAL AGENT:
VX NERVE AGENT
[CAS Nos. 50782-69-9, 51848-47-6]
[53800-40-1, 70938-84-0]
Prepared for the National Academies
by
The Center for Research Information, Inc.
9300 Brookville Rd
Silver Spring, MD 20910
http:// www.medresearchnow.com
(301) 346-6501
[email protected]
2004
ACKNOWLEDGEMENTS
This report and any supplements were prepared by the Center for Research
Information, Inc. which is solely responsible for its contents.
Although this draft is the definitive submission on its subject matter, the Center for
Research Information recognizes its ethical and contractual obligation to update,
revise, or otherwise supplement this report if new or necessary information on its
subject matter should arise, be requested, or be ascertained during the contract
period.
The Principal Investigator wishes to acknowledge and thank Matthew Hogan, Linda
Roberts, Lawrence Callahan, Judith Lelchook and Emnet Tilahun for research
assistance, editorial content assistance, and project input.
ii
This report deals primarily with the biological health challenges engendered by the agent
that is the subject of the report. Nevertheless, this report also incorporates, by reference
and attachment, a supplement entitled "Psychogenic Effects of Perceived Exposure to
Biochemical Warfare Agents".
The supplement addresses and describes a growing body of health effects research and
interest centered upon the psychogenic sequelae of the stress experienced personally from
actual or perceived exposure to chemical and biological weaponry. Because awareness
of exposure to agents in Project SHAD logically includes the exposed person also
possessing a perception of exposure to biochemical warfare agents, the psychogenic
health consequences of perceived exposure may be regarded as additional health effects
arising from the exposure to Project SHAD agents. This reasoning may also apply to
simulants and tracers. Therefore, a general supplement has been created and submitted
under this contract to address possible psychogenic effects of perceived exposure to
biological and chemical weaponry.
Because such health effects are part of a recent and growing public concern, it is expected
that the supplement may be revised and expanded over the course of this contract to
reflect the actively evolving literature and interest in the issue.
iii
TABLE OF CONTENTS
I. EXECUTIVE SUMMARY..
II. BACKGROUND DATA:
CHEMISTRY & HISTORY
Chemistry.
Historical Background
Use As Terror or Military Weapon
5
5
6
8
10
Pathophysiology 10
Diagnosis... 10
12
12
13
14
14
15
16
16
16
16
17
17
17
V. PSYCHOGENIC EFFECTS..
19
20
22
23
iv
I. EXECUTIVE SUMMARY
VX Nerve Agent (VX) is a chemical warfare nerve agent. Its chemical formula is
C11H26NO2PS. Its formal chemical name is O-Ethyl S-(2-diisopropylaminoethyl)
methylphosphonothiolate. Due to the existence of several isomers, VX has several CAS
(Chemical Abstracts Service) registry numbers: 50782-69-9, 51848-47-6, 53800-40-1,
and 70938-84-0.
VX is an organophosphate compound and it belongs to the specific class of compounds
known as the phosphonothiocholines. The "V" in VX stands for "venom," a tribute to
this compound class having high potency and a characteristic ability to penetrate the skin.
At normal temperatures, it is an oily liquid of low volatility with viscosity similar to
motor oil.
Ranaji Ghosh first synthesized VX in the early 1950s. The British government noted
VX's potential as a warfare agent and shared its research with the U.S Army Edgewood
facility. Eventually large quantities of VX were produced through the 1960s at a
Newport Indiana facility. Some stocks still remain there and on other bases and have
been slated for destruction in 2004. The Soviet Union developed a related compound
called Russian VX (O-Isobutyl S-(2-diethylamino) methylphosphonothioate).
VX has been the subject of accidental releases, controlled releases, and has been used as
a weapon. The largest reported accidental release occurred at Utah's Dugway Proving
Grounds on March 13, 1968 when approximately 9 kg of VX drifted over adjacent
grazing land, killing over 6000 sheep. There was also an accidental release of a nerve
agent (sources conflict on whether VX was involved) at a storage facility in Okinawa in
1969, which resulted in the hospitalization of 23 military personnel and one civilian. In
Project SHAD at least two test releases on ships have been reported.
In addition to releases by the US Army, VX was used by the Aum Shinrikyo cult in Japan
to kill several dissident members, and others opposed to the cult. It may have also been
used by Iraq as part of a cocktail in the Iran-Iraq war and to quell Kurdish uprisings in the
1980s. US troops were exposed nerve agents during destruction and disposal operations
in the Gulf War, though VX is not reported to be among those agents.
VX is a potent and selective inhibitor of acetylcholinesterases (AChE), which results in
the accumulation of acetylcholine in the synapses of both central and peripheral nerves.
VX, in contrast to other nerve agents inhibits AChE significantly more than plasma
cholinesterases. VX exposure and action results in intense stimulation of nicotinic,
muscarinic, and central nervous system (CNS) receptors. Toxic effects are generally seen
when over 50% of the AChE enzyme is inhibited. Death typically occurs when over 90%
of the AChE enzyme is inhibited. Death is usually due to inhibition of the enzyme in the
brain and diaphragm.
activity and death in the absence of medical treatment. Neuropsychiatric effects including
loss of memory and depression are also seen but are relatively short-lived following
exposure to VX .
The onset of symptoms can take hours when sublethal doses are applied to the skin. A
small drop may initially cause localized muscle twitching and sweating, followed by
nausea, vomiting, diarrhea and generalized weakness. These symptoms typically last for
several hours. Systematic dermal studies in humans showed vomiting occurred in 33%
and 67% of subjects when red blood cholinesterase activity was 30-39% and less than
20% of control activity. Other studies have shown that a dose of 5 mg/kg of VX resulted
in systemic toxicity in roughly half of the subjects. Persons whose skin is exposed to
higher doses of VX may show no symptoms for up to 30 minutes, but then rapidly suffer
loss of consciousness, convulsions, difficulty breathing, profuse secretions from nose and
mouth, generalized muscle twitching, paralysis and death. At lethal and near-lethal levels
of exposure loss of consciousness, convulsions, flaccid paralysis, and apnea are seen. At
high doses there is also a more rapid onset of signs and symptoms. Clothing, site of skin
exposure, and temperature can greatly affect the nature and toxicity of dermal exposure.
Animal studies have indicated VX can cause cardiac effects, although these effects have
not been seen in human volunteer studies. Arrhythmias were seen both in rats and dogs at
doses that did not result in convulsions. Electrophysiological studies using guinea pig
heart tissue showed that VX exposure led to a positive inotropic effect, two contractile
events in response to each stimulation and the development of delayed afterdepolarizations. VX cardiac toxicity has been attributed to the inhibition of the rat
cardiac Na+,K(+)-ATPase alpha 1 isoform.
Few studies have addressed long-term toxicity or effects of nerve agents in general and
VX in particular. Textbooks indicate that most if not all of the effects of nerve agents
dissipate within months after exposure. The results of a recent telephone survey of over
4000 volunteers who had participated in programs that involved exposure to chemical
agents between 1955 and 1975 at Edgewood MD found fewer attention problems as the
only statistically significant differences between those exposed to nerve agents and those
exposed to other chemical agents but it also found greater sleep disturbances in
volunteers who had been exposed to nerve agents. VX differs from other nerve agents in
that it does not appear to undergo aging or stabilization but does to undergo spontaneous
reactivation
Unlike many other organophosphates, VX also has not been shown to induce a syndrome
called organophosphorus-induced delayed neuropathy (OPIDN). OPIDN results from the
inhibition of the enzyme neuropathy target esterase (NTE; also termed neurotoxic
esterase). VX has been reported to be at least 1000 times less effective than sarin in
inhibiting NTE. The failure of VX to inhibit neuropathy target esterase and cause
organophosphorus-induced delayed neuropathy together with the inability of to age
when bound to AchE or other proteins indicates that VX may not cause much of the longterm toxicity associated with other organophosphates.
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
VX has tested negative in a number of assays for mutagenicity, with and without
metabolic activation. Human studies in personnel working with VX on a daily basis
found no increased incidence of cancer. The teratogenic potential of VX has also been
evaluated in sheep, rats and rabbits; all have all been negative for teratogenicity. VX has
not been deemed a carcinogen by any authority.
In regard to long-term neurotoxicity, VX has not been shown to have delayed or
persistent psychological effects or to result in any long-term EEG changes.
Organophosphorus-induced delayed neuropathy (OPIDN) has not resulted from VX
exposure. Convulsions without treatment can lead to permanent neuropathogical
damage.
Brain damage has been seen in animals injected with VX. Microinjections of VX into the
amygdala resulted in convulsions and resultant neuropathology. Much of the brain
damage that has been observed is believed to be due from the induction of convulsions
and not the direct toxic actions of VX. Studies on neuroblastoma cells have indicated
that VX displays some toxicity presumably through binding to muscarinic receptors.
No studies have been found addressing purely psychogenic effects arising from an
awareness of, or a perception of, exposure to VX specifically. But the use of another
organophosphate agent (sarin) in terror attacks in Japan in the 1990s has led to some
investigation and consideration of the possible psychogenic effects of exposure to a nerve
agent. Discussion of those reports appear in the review prepared under this contract for
the health effects of sarin. Information on the general psychogenic effects of perceived
exposure to biological or chemical warfare agents is contained in the supplement report
under this contract Psychogenic Effects of Perceived Exposure to Biochemical Warfare
Agents.
There have been several approaches towards the treatment of, and protection against, VX
exposure. Barrier methods, including garments, respirators and even protective creams
have been developed that will protect against even high levels of VX exposure. The use
of reversible inhibitors of AChE to protect against subsequent exposure to nerve agents
has been pursued extensively by the US military. Pyridostigmine bromide was used by a
large number of troops during the Gulf War to protect against possible exposure to
Soman and other nerve agents. Several studies since then have implicated
pyridostigmine as a potential contributory factor in the induction of Gulf War Syndrome,
a multi-symptom illness found in a number of veterans who served in Iraq. Other reports
have since questioned its utility in protecting against VX exposure.
Several other agents have also been proposed for prophylaxis against nerve agent
exposure. Both physostigmine and hyoscine has been reported superior to
pyridostigmine in preventing the death of animals following VX exposure. Huperzine
has also been found to be a more effective prophylactic agent than pyridostigmine. In
contrast to other prophylactic agents, huperzine does not inhibit butyryl-cholinesterase
(plasma) which can then still act to scavenge nerve agents.
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
CH3
N
CH3
H3C
CH3
Historical Background
The use of chemical warfare agents is probably nearly as old as war itself. Early
documented uses of chemical warfare agents include: the Chinese use of arsenical smoke
as early 1000 BC; the use of hellebore roots by Athenian soldiers to poison the drinking
water of Kirrha in 600 BC; the use of sulfur dioxide and other noxious fumes by the
Spartans against the Athenians during the Peloponnesian Wars; and the use of mandrake
root laced wine by the Carthaginians to sedate Roman soldiers in 200 BC. The most
extensive use occurred during World War I when the use of both chlorine and mustard
gases resulted in over one-million casualties (Eckert 1991, Landersman 2003, Smart
1997).
VX is a member of a more recent class of organophosphate chemical compounds termed
phosphorylthiocholines or phosphonylthiocholines. This class was initially discovered
independently by Ranaji Ghosh of Imperial Chemicals Inc. (ICI), Gerhard Schrader of
Bayer, and by Lars-Erik Tammelin of the Swedish Institute of Defense Research in 19521953. The compounds were first developed as insecticides, but soon thereafter the
human toxicity of the compounds also became evident. One of the compounds, Amiton,
(VG; O,O-Diethyl-S-[2-(diethylamino)ethyl] phosphorothioate) was actually brought to
market by ICI but withdrawn after discovery of its human toxicity. By 1953, the British
recognized the potential of these compounds as chemical warfare agents. (The V in the
V-class of phosphorylthiocholine compounds stands for "venom", a term derived from
the V-class members' high potency and ability to penetrate the skin (CBWInfo 2004,
Mitretek 2004, Reutter 1999, Smart 1997)).
First synthesized by Ghosh around 1955, VX is the most widely studied of the
phosphorylthiocholine class of compounds. After its synthesis, the toxicity and physical
properties of VX were studied by chemical warfare specialists at Porton Down in Britain,
who shared their information with the US Armys Edgewood facility. Those
investigations led to VX being chosen as the US Armys second-generation nerve agent.
A patent dispute, requiring at one point an injunction from the Chief Justice of the United
States for its resolution, delayed the onset of production. Finally, in 1959, the FMC
Corporation was awarded a contract for the mass production of VX. A former Atomic
Energy plant in Newport, Indiana, which produced heavy water, was adapted by FMC for
VX production. The plant was designed to make up to 10 tons of VX per day. It
operated from 1961 to 1968 (Smart 1997). The Army also developed a number of shells,
rocket missiles and even land mines that were capable of dispersing VX. Many of these
weapons were stored at Army bases throughout the world (Smart 1997).
There are still over 1200 tons of VX stored at the Newport facility. The destruction of
the stockpile has been scheduled to begin during the summer of 2004. Destruction is set
to be carried out by hydrolyzing VX with water and sodium hydroxide at a temperature
of 195oC (CNN 2004).
VX has been involved in several accidental releases and several controlled releases by the
US military. The largest reported accidental release occurred at Utah's Dugway Proving
Grounds on March 13, 1968 when a portion or all of over 9 kg of sprayed VX drifted
over adjacent grazing land, killing over 6000 sheep. There was also an accidental release
of a nerve agent at a storage facility in Okinawa in 1969, which resulted in the
hospitalization of 23 military personnel and one civilian. One source has reported that
this incident involved VX (CBWInfo 2004), while another source states the incident
involved sarin (Smart 1997).
Controlled releases of VX reported by the Army as part of Project SHAD include: Flower
Drum Phase 2 in 1964, when VX was sprayed onto a barge and Fearless Johnny in
1965 which the George Eastman, a Navy cargo ship, was also sprayed. Both of the
releases were meant to test decontamination and protective equipment and both occurred
off the coast of Hawaii (Special Assistant 2004).
The accidental releases coupled with reports of intentional releases led to action by
Congress and President Nixon to ban the production of biological weapons and to
severely limit the development and production of chemical weapons. Although Nixon
effectively ended the production of US chemical weapons, research continued on binary
weapons. Binary weapons are weapons in which two less toxic chemicals, initially
separated in a shell, are mixed upon firing and undergo a chemical reaction to form a
potent chemical warfare agent. The Army ultimately did develop a binary weapon, code
named Bigeye, which was capable of forming VX upon firing. Bigeye, however, never
went into full production. The collapse of the Soviet bloc spelled the end of the Armys
offensive chemical warfare program. On June 1, 1990, the United States and the Soviet
Union signed a bilateral agreement to destroy all chemical weapons. This effectively
ended the US offensive chemical weapons program (Smart 1997).
Although the Soviet Union did not develop VX, they developed a very similar compound
usually called Russian VX (R-VX; O-Isobutyl S-(2-diethylamino)
methylphosphonothioate). The production of this chemical did lead to slow chronic and
apparently irreversible toxicity in workers who produced the nerve agent (Gur'eva et al.
1997).
In addition to releases by the US Army, VX was developed and used by the Aum
Shinrikyo in Japan to kill several dissident members and others thought to be opposed to
the cult. It may have also been used by Iraq as part of a cocktail in the Iran-Iraq war or to
quell Kurdish uprisings in the 1980s (CBWInfo 2004). The following subsection details
these actual and reported uses of VX as a weapon.
Use As Terror or Military Weapon
Aum Shinrikyo, a religious cult founded in Japan by Asahara Shoko in the 1980s, used
both VX and sarin to kill opponents and create panic throughout Japan. Although the
sarin attacks on a residential area in Matsumoto in 1994 and on the subway in Tokyo in
1995 are well known, the cult experimented and used a number of other toxic substances
Contract No. IOM-2794-04-001
8
Health Effects of VX Nerve Agent
including VX. VX was reportedly used to kill as many as twenty people including
dissident cult members, opponents of the cult, and members of the general population.
Aum Shinrikyo also used VX in several attacks that were unsuccessful. Most victims
were directly squirted with VX in the head or neck region, although in one case that was
unsuccessful, VX was applied to the door handle of a car that the intended victim used
(Monterey Institute, 2001, Tsuchihashi et al. 1998).
The synthesis of both VX and sarin by the cult appears to have been accomplished in a
relatively short period of time by a group of chemists from Japanese universities under
the supervision of Masami Tsuchiya, a former Ph.D. student at Tsukuba University. Mr.
Tsuchiya was recently sentenced death for his role in the synthesis of these toxins (BBC
2004). The ability of Aum Shinrikyo to synthesize small quantities of VX from
commercially available starting materials in a non-industrial setting indicates that VX
may be used in the future by both government and non-government sponsored
organizations (Department of Defense 1998).
Iraq, under Saddam Hussein, was reported to have produced over 50 tons of VX. VX
may have been used as part of a cocktail in attacks against the Kurds and against Iranians
during the Iran-Iraq war. There also is evidence that Iraq weaponized VX and deployed
it in artillery shells. There is no evidence, however, that Saddam Hussein intentionally
used VX or any other nerve agents during the Gulf War, although there is evidence that
low levels of nerve agents were released as result of the bombing of munitions dumps
and the destruction of munitions by coalition troops. One of these incidents did lead to
exposure of US troops to nerve agents when rockets were destroyed at the Khamisiyah
Pit. Those nerve agents, however, appear to have been sarin and cyclosain, not VX (CIA
2002).
There have also been reports that Al Qaeda pursued VX, although it is unlikely that they
were successful. One of the justifications for the bombing of a pharmaceutical plant in
Sudan was that it was producing VX. This was later shown to be untrue. It is doubtful
that Al Qaeda currently has the technical capability to manufacture VX (Council on
Foreign Relations 2004, CBWInfo. 2004).
enzymatic hydrolysis of VX. In the particular case studied, VX poisoning was not
confirmed until six months after the victims death (Tsuchihasi et al. 1998).
In addition to specifically identifying VX or nerve agent metabolites, several tests have
been developed that attempt identify nerve agent poisoning through the quantification of
cholinesterase activity in blood. The monitoring of AChE activity in blood has been
shown to be a reliable marker for systemic toxicity. There are two types of cholinesterase
(ChE) in blood: red blood cell ChE, which is very similar to ChE released at nerve
synapses, and a nonspecific plasma ChE (butyryl cholinesterase or pseudocholinesterase).
Red blood cell AChE is very similar to AChE released at nerve synapses. Systemic toxic
effects are seen in approximately 50% of subjects when 75% of their red blood cell
AChE is inhibited (Munro et al. 1994).
The Test-Mate OP Kit developed by the EQM Corporation has been chosen by the Army
to monitor potential organophosphate poisoning. The test kit is compact and uses a
single drop of blood to measure levels of both acetylcholinesterase present in red blood
cells and butyryl-cholinesterase or pseudocholinesterase. The test is to be used in the
field and in clinical labs to monitor levels of organophosphate exposure (Garcia et al.
2004).
A more recent test relies on the ability of potassium fluoride to reactivate plasma
enzymes such as butyryl-cholinesterase. Upon reactivation a phosphofluoridate or
phosphonofluoridate is formed which can then be identified and quantitated using gas
chromatography. This technique is very sensitive and can be used to monitor low levels
of exposures. It can also be used retrospectively to determine if exposure occurred weeks
or even months previously. This technique can unambiguously identify both nerve
agents and pesticides (Van Der Schans et al. 2004).
11
12
LD50 ; LCt50
36
50
15
25
8-30
17
7-40
0.04-0.14
0.065
0.4
0.054
Units
mg . min/m3
mg . min/m3
mg . min/m3
mg . min/m3
mg . min/m3
mg . min/m3
mg . min/m3
mg/kg
mg/kg
mg/kg
mg/kg
13
Cat
Rabbit
Rat
Mice
Human
Goat
Dog
Cat
Rabbit
Guinea Pig
Rat
Mice
Rat
Hen
Dermal
Dermal
Dermal
Dermal
Intravenous
Intravenous
Intravenous
Intravenous
Intravenous
Intravenous
Intravenous
Intravenous
Subcutaneous
Intramuscular
0.012
0.025
0.1
0.046
8
5
6.3
2.5
8.4
4.5
7.9
14.1
21
30
mg/kg
mg/kg
mg/kg
mg/kg
g/kg
g/kg
g/kg
g/kg
g/kg
g/kg
g/kg
g/kg
g/kg
g/kg
10-min
Conc.
0.0002
mg/m3
0.0024
mg/m3
0.0096
mg/m3
30-min
Conc.
0.00011
mg/m3
0.0014
mg/m3
0.0049
mg/m3
1-hour
Conc,
0.00008
mg/m3
0.00098
mg/m3
0.0033
mg/m3
4-hour
Conc,
0.00004
mg/m3
0.00049
mg/m3
0.0017
mg/m3
8-hour
Conc.
0.000028
mg/m3
0.00035
mg/m3
0.0013
mg/m3
Since actual animal and human inhalation studies were lacking for VX, these levels were
derived from the relative potency of VX compared to sarin (Hartmann 2002).
14
Dermal Exposure
VX has the viscosity of motor oil but it is less volatile. It is significantly more toxic than
any other nerve agent following skin exposure. Unlike G-type agents, VX can act
predominantly via the percutaneous route. VX is not detoxified by the skin and reacts
very little, if at all, with plasma cholinesterases (Munro et al. 1994).
The amount of VX absorbed is dependent on the thickness and penetrability of skin as
well the temperature. Studies on guinea pigs and marmosets indicate that approximately
2.5% of VX applied to the skin reaches the blood. These studies also indicated that
isomers of VX have equivalent bioavailability (Van der Schans et al. 2003). Studies in
swine showed that bioavailability varied depending on the site of application. VX applied
in the ear region showed much greater bioavailability than that applied to the epigastrium,
perineum, or inguinal crease (Duncan et al. 2002).
Studies in human volunteers have also shown that VX absorption is highly dependent on
site and temperature during exposure. The fraction of the applied dose of VX that
penetrated the skin when applied to the cheek ranged from 3.5% at 18 oC to 31.9% at 46
o
C over a three hour time period. Only 0.4% at 18 oC to 2.9% at 46 oC penetrated the
skin when VX was applied to the forearm (Craig et al. 1977). The time between VX
exposure and the maximal effect can also depend on the site of exposure. In studies
where small equipotent amounts VX were applied to the skin, the maximal effect was
seen at 5 hours when applied to the head or neck, 7 hours when applied to the extremities,
and 10 hours when applied to the torso (Sidell 1997).
Clothing can also have an effect upon VX absorption. Dry clothing has been estimated to
reduce the dermal toxicity of VX 6- to10-fold. Sweated clothing, however, will only
reduce adsorption by 3-fold (Munro et al. 1994, Wester et al. 2000).
Signs and symptoms following exposure to the skin begin within 0.5-18 hours. A small
drop may at first cause localized muscle twitching and sweating, followed by nausea,
vomiting, diarrhea and generalized weakness. These symptoms typically last for several
hours. Systematic dermal studies in humans showed vomiting occurred in 33% and 67%
of subjects when red blood cholinesterase activity was 30-39% and less than 20% of
control activity. Other studies have shown that a dose of 5 g/kg of VX resulted in
systemic toxicity in roughly half of the subjects (National Research Council (US) 1999).
Persons whose skin is exposed to higher doses of VX may show no symptoms for up to
30 minutes, but thereafter may rapidly suffer loss of consciousness, convulsions,
difficulty breathing, profuse secretions from nose and mouth, generalized muscle
twitching, paralysis and death. At lethal and near-lethal levels of exposure loss of
consciousness, convulsions, flaccid paralysis, and apnea are seen. At high doses there is
also a more rapid onset of signs and symptoms (Sidell 1997, Emedicine 2004).
15
Oral Exposure
The low volatility and environmental persistence of VX make ingestion a relevant
potential route of human exposure. Studies involving human volunteers have shown that
that the oral toxicity is about 3-fold less than IV toxicity. At oral doses ranging from
0.002-0.0045 mg/kg only a few subjects (5/32) displayed gastrointestinal signs or
symptoms. No changes were observed in the heart rate, blood pressure, mental
performance, and pupil size in any of the subjects. Eating prior to ingestion also
appeared to increase the bioavailability of VX (Sidell et al. 1974). An earlier study also
showed no effect in volunteers who were orally dosed at 0.00143 mg/kg over a period of
7 days (Munro et al. 1994).
Intravenous (IV) Exposure
Several studies have addressed the IV toxicity of VX in humans. A group that received
0.0015 mg/kg saw a significant decrease in mental performance for one hour after the
injection. Nausea, vomiting were seen as well (Sidell et al. 1974). Subjects who received
0.001 mg/kg over a 1.75- to 4-hr period showed no signs of toxicity, other than a
headache in one patient, even though there was a 50-60% reduction in red blood cell
AChE. Studies in which 0.00008 mg/kg was administered over a 30 sec period resulted
in headaches, lightheadedness and abdominal cramps, even though there was no decrease
in red blood cell AChE (National Research Council (US) 1999).
Inhalation Exposure
Signs and symptoms from vapor exposure generally manifest within seconds or minutes.
These typically include miosis or pinpoint pupils, eye pain, running nose, difficulty
breathing and productive coughing (Emedicine 2004). Nausea and vomiting may also
occur, but the onset is usually later. Exposure to higher doses results in severe dyspnea,
along with gastrointestinal and neuromuscular effects. Exposure to lethal or near lethal
doses leads to loss of consciousness, flaccid paralysis, convulsions and apnea (Sidell
1997).
Cardiac Effects
Although cardiac effects were not seen in any of the studies involving human volunteers,
animal studies have indicated VX may cause cardiac effects. Arrhythmias were seen both
in rats and dogs at doses that did not result in convulsions (Robineau 1987, Robineau et
al. 1987). Electrophysiological studies using guinea pig heart tissue showed that VX
exposure led to a positive inotropic effect, two contractile events in response to each
stimulation and the development of delayed after-depolarizations (Corbier et al. 1989).
VX cardiac toxicity in rats has been attributed to the inhibition of the rat cardiac
Na+,K(+)-ATPase alpha 1 isoform. At 1 M concentration VX inhibited the cardiac
Na+,K(+)-ATPase by 35%. This inhibition is believed to account for cardiac toxicity
seen with VX (Robineau et al. 1991).
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
16
17
1992). Again, it is not clear whether human exposure specifically to VX will result in
long term effects since VX inhibited enzymes and receptors undergo spontaneous
reactivation and do not appear to undergo aging (Sidell et al. 1974). No studies report or
ascribe long-term human neurological clinical health effects to VX exposure.
Brain damage has been seen in animals injected with VX. Microinjections of VX into the
amygdala resulted in convulsions and resultant neuropathology. Injection of 3.4
nanomoles of VX into the amygdala of rats resulted in convulsions and brain damage in
67% of the animals treated. It should be noted that much of the brain damage that has
been observed is believed secondary in nature to VX exposure, as it is regarded to be due
to the induction of convulsions and not to the results of direct toxic actions by VX
(McDonough et al. 1987). Convulsions induced by organophosphate agents, without
subsequent treatment, have been shown to lead to permanent neuropathological damage
(Tuovinen 2004).
In vitro studies on human neuroblastoma cells have indicated that VX displays some
direct cytotoxicity presumably through binding to muscarinic receptors (Cao et al. 1999).
18
V. PSYCHOGENIC EFFECTS
No studies have been found addressing psychogenic effects arising from an awareness of,
or a perception of, exposure specifically to VX. But the use of another organophosphate
agent (sarin) in terror attacks in Japan in the 1990s led to some investigation and
consideration of the possible psychogenic effects of exposure to a nerve agent.
Discussion of those reports appear in the review prepared under this contract for the
health effects of sarin.
Information on the general psychogenic issues and effects of perceived exposure to
biological or chemical warfare agents is contained in the supplement report under this
contract Psychogenic Effects of Perceived Exposure to Biochemical Warfare Agents.
19
20
A subject's skin and hair should be extensively washed with large amounts of soap and
water but water and soap from the hair should not come in contact with the skin. A
decontamination solution consisting of either household bleach or 10% sodium
bicarbonate can also be used. Casualties should be decontaminated as fast as possible but
should not be moved into clean treatment areas until decontamination is complete.
Bleach should be used extensively to decontaminate any area or material where exposure
has occurred (CBWInfo. 2004).
Atropine sulfate, an anticholinergic agent, should be administered to the exposed
individual as soon as possible following decontamination. An initial intravenous dose of
2 mg should be given, followed by additional doses every 10-15 minutes until
bradycardia subsides. Intramuscular injections should be considered if the patient is
hypoxic and ventilation cannot be initiated. Oxygen or oxygen rich air should be used for
ventilation if available. Oximes, such as pralidoxime salts, should also be administered
as soon as possible to help regenerate AChE enzymes. Typically, 500 mg1 g of
pralidoxime is administered through a slow intravenous infusion (CBWInfo. 2004,
Newmark 2004). Several other oximes such has K048, HI-6, obidoxime have been
shown to reactivate AChE enzymes. K048 has been reported to be the more effective
than the other agents in reactivating AChE inhibited by VX (Kuca et al. 2003). Another
oxime, TO205, has recently been reported to be the most efficacious agent the
reactivation of VX-inhibited AChE (Kuca et al. 2004).
Early intervention to prevent or treat convulsions is an essential component in the
treatment of nerve agent poisoning. An initial 5 mg dose of diazepam, a full allosteric
modulator of GABA action, followed by additional doses every 15 minutes up to 15 mg
is typically given following VX exposure (CBWInfo. 2004). Imidazenil, a partial
selective allosteric modulator of GABA action, has been shown to be more effective than
diazepam in protecting rats against organophosphate-induced convulsions and death
(Auta et al. 2004).
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Auta et al. 2004. Imidazenil: a potent and safe protective agent against diisopropyl
fluorophosphate toxicity. Neuropharmacology. 46(3):397-403.
Convulsions are major and life-threatening signs of organophosphate (OP) nerve agents
induced neurotoxicity. Thus, early intervention with anticonvulsant drugs to control
seizure propagation and the consequent irreversible neuronal damage that may occur
during OP exposure is essential. Diazepam is the standard anticonvulsant used in the
therapeutic management of OP poisoning. However, its use has been associated with
several unwanted effects including, sedation, amnesia, and in the large doses used for
such treatment, respiratory depression. Moreover, protracted administration of diazepam
has been associated with tolerance and dependence liabilities. In this study, we compared
the efficacy and safety of diazepam (full allosteric modulator of GABA action) to that of
imidazenil (partial, selective allosteric modulator of GABA action) as preventive
treatment against diisopropyl fluorophosphate (DFP)-induced convulsions and mortality.
Our results show that imidazenil is more potent and efficacious than diazepam in
protecting rats against DFP-induced convulsions and death. Moreover, imidazenil was
effective at doses (1 and 0.5 mg/kg) we have previously shown to be devoid of sedation,
amnesia, respiratory depression, or tolerance and/or dependence. In contrast, diazepam
was effective at doses (5 and 2.5 mg/kg) that produce sedation, amnesia, and ataxia.
Furthermore, the combination of imidazenil with atropine was more potent and
efficacious than that with diazepam.
Bakry et al. 1998. Direct actions of organophosphate anticholinesterases on nicotinic and
muscarinic acetylcholine receptors. J Biochem Toxicol. 3:235-59.
Four nerve agents and one therapeutic organophosphate (OP) anticholinesterase (antiChE) bind to acetylcholine (ACh) receptors, inhibit or modulate binding of radioactive
ligands to these receptors, and modify events regulated by them. The affinity of nicotinic
(n) ACh receptors of Torpedo electric organs and most muscarinic (m) ACh receptors of
rat brain and N1E-115 neuroblastoma cultures for the OP compounds was usually two to
three orders of magnitude lower than concentrations required to inhibit 50% (IC-50) of
ACh-esterase activity. However, a small population of m-ACh receptors had an affinity
as high as that of ACh-esterase for the OP compound. This population is identified by its
high-affinity [3H]-cis-methyldioxolane ([3H]-CD) binding. Although sarin, soman, and
tabun had no effect, (O-ethyl S[2-(diisopropylamino)ethyl)] methyl phosphonothionate
(VX) and echothiophate inhibited competitively the binding of [3H]-quinuclidinyl
benzilate ([3H]-QNB) and [3H]-pirenzepine ([3H]-PZ) to m-ACh receptors. However,
VX was more potent than echothiophate in inhibiting this binding and 50-fold more
potent in inhibiting carbamylcholine (carb)-stimulated [3H]-cGMP synthesis in N1E-115
neuroblastoma cells--both acting as m receptor antagonist. All five OPs inhibited [3H]CD binding, with IC-50s of 3, 10, 40, 100, and 800 nM for VX, soman, sarin,
echothiophate, and tabun, respectively. The OP anticholinesterases also bound to
allosteric sites on the n-ACh receptor (identified by inhibition of [3H]-phencyclidine
binding), but some bound as well to the receptor's recognition site (identified by
inhibition of [125I]-alpha-bungarotoxin binding). Soman and echothiophate in
micromolar concentrations acted as partial agonists of the n-ACh receptor and induced
receptor desensitization. On the other hand, VX acted as an open channel blocker of the
activated receptor and also enhanced receptor desensitization. It is suggested that the
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
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26
measured over a 6-h time period. The dose absorbed at the ear region was 11 microg cm(2) with an initial flux of 0.063 microg cm(-2)min(-1), whereas at the epigastrium region
the dose absorbed was 3 microg cm(-2) with an initial flux of 0.025 microg cm(-2)min(1). For this reason further studies were carried out with VX on the ear and the
epigastrium only. In animals treated with agent on the epigastrium, blood cholinesterase
(ChE) activity began to drop 90 min after application and continued to decline at a
constant rate for the remainder of the experiment to ca. 25% of awake control activity. At
this time there were negligible signs of poisoning and the medical prognosis was judged
to be good. In contrast, the ChE activity in animals receiving VX on the ear decreased to
25% of awake control values within 45 min and levelled out at 5-6% by 120 min. Clinical
signs of VX poisoning paralleled the ChE inhibition, progressing in severity over the
duration of the exposure. It was judged that these animals would not survive. The
dramatic site dependence of agent absorption leading to vastly different toxicological
endpoints demonstrated in this model system has important ramifications for chemical
protective suit development, threat assessment, medical countermeasures and
contamination control protocols.
Duysen et al. 2001. Evidence for Nonacetylcholinesterase Targets of Organophosphorus
Nerve Agent: Supersensitivity of Acetylcholinesterase Knockout Mouse to VX Lethality.
J Pharmacol Exp Ther. 299(2):528-35.
The possibility that organophosphate toxicity is due to inhibition of targets other than
acetylcholinesterase (AChE, EC 3.1.1.7) was examined in AChE knockout mice. Mice
(34-55 days old) were grouped for this study, after it was determined that AChE,
butyrylcholinesterase (BChE), and carboxylesterase activities had reached stable values
by this age. Mice with 0, 50, or 100% AChE activity were treated subcutaneously with
the nerve agent VX. The LD50 for VX was 10 to 12 g/kg in AChE/, 17 g/kg in
AChE+/, and 24 g/kg in AChE+/+ mice. The same cholinergic signs of toxicity were
present in AChE/ mice as in wild-type mice, even though AChE/ mice have no AChE
whose inhibition could lead to cholinergic signs. Wild-type mice, but not AChE/ mice,
were protected by pretreatment with atropine. Tissues were extracted from VX-treated
and untreated animals and tested for AChE, BChE, and acylpeptide hydrolase activity.
VX treatment inhibited 50% of the AChE activity in brain and muscle of AChE+/+ and
+/ mice, 50% of the BChE activity in all three AChE genotypes, but did not significantly
inhibit acylpeptide hydrolase activity. It was concluded that the toxicity of VX must be
attributed to inhibition of nonacetylcholinesterase targets in the AChE/ mouse.
Organophosphorus ester toxicity in wild-type mice is probably due to inhibition or
binding to several proteins, only one of which is AChE.
Eckert 1991. Mass deaths by gas or chemical poisoning. A historical perspective. Am J
Forensic Med Pathol. 12(2):119-25.
This review chronicles the characteristics of deliberate and accidental mass poisonings
that occurred in World Wars I and II, in Bhopal, and in other historical cases up to and
including modern wars. It also considers approaches to the investigation of such cases
from the medicolegal as well as general standpoints.
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Mechanical ventilation may be required. Convulsions are treated with diazepam, but only
after atropine has been administered.
Gur'eva et al. 1997. Chronic poisoning by organophosphoric VX. Med Tr Prom Ekol.
(6):7-11.
Long-term observation of workers engaged into production of VX chemical diagnosed
slow progressing manifestation of chronic occupational poisoning with the chemical. The
characteristic nervous, digestive, locomotory, visual and cardiovascular symptoms were
revealed. The authors presented laboratory and instrumental data on the cases. As the
treatment appeared ineffective, further adjustment and improvement of the therapy is
required. The article demonstrated the main underlying metabolic disorders that could be
addressed by the pathogenetic therapy.
Hartmann 2002. Evaluation of risk assessment guideline levels for the chemical warfare
agents mustard, GB, and VX. Regul Toxicol Pharmacol. 35(3):347-56.
The U.S. Army has estimated acute lethality guideline levels for inhalation of the
chemical warfare agents mustard, GB, and VX. These levels are expressed as dosages
measured in milligram-minutes per cubic meter (mg-min/m(3)). The National Advisory
Council has also proposed acute emergency guideline levels (AEGLs) for the agents. The
AEGLs are threshold exposure limits for the general public for mild effects, serious
adverse effects, and lethality. They are expressed as air concentrations (in units of
mg/m(3)) and are applicable to emergency exposure periods ranging from 10 min to 8 h.
The report discusses strengths and deficiencies in the levels, important parameters (i.e.,
exposure time, breathing rate) that need to be explicitly addressed in deriving the
guideline levels, and possible impacts that could result from using AEGLs instead of
guideline dosages in future assessments.
Hayes et al. 2004. Feasibility of direct analysis of saliva and urine for phosphonic acids
and thiodiglycol-related species associated with exposure to chemical warfare agents
using LC-MS/MS. J Med Chem Def 2:1-23 (9 Aug 2004) available at
http://jmedchemdef.org/Issue_0201/Kenny_0804.html.
A sensitive method based on high performance liquid chromatography tandem
massspectrometry (LC-MS/MS) has shown the feasibility of separation and detection of
lowlevelthiodiglycol-related species in saliva and of nerve agent phosphonic acids in
salivaand urine. The analysis of these thiodiglycol-related species and phosphonic acids
are ofinterest since they are specific metabolites of the chemical warfare agents (CWAs)
sulfurmustard (HD), Sarin (GB), Soman (GD), GF, and VX. The liquid
chromatographyatmosphericpressure chemical ionization tandem mass spectrometry (LCAPCI-MS/MS)and liquid chromatography electrospray ionization tandem mass
spectrometry (LC-ESIMS/MS) methods developed provide a sensitive and direct
approach for determiningCWA exposure in non-extracted non-derivitized samples from
saliva and urine.Chromatographic separation of the thiodiglycol-related species was
achieved using areverse phase high performance liquid chromatography (HPLC) column
with an isocraticmobile phase of 93% water, 20 mM formic acid, 20 mM ammonium
formate, and 7%methanol. Chromatographic separation of the phosphonic acids was
achieved using areverse phase HPLC with gradient mobile phases consisting of 0.1%
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
29
acetic acid in waterand 0.1% acetic acid in methanol. Identification and quantification of
species wasachieved using both atmospheric pressure chemical ionization and
electrosprayionization-tandem mass spectrometry monitoring two precursor-to-product
ion transitionsfor each compound, as well as internal standards. The concentration vs
response waslinear between 10 ng/mL and 500 ng/mL. Instrument detection limits ranged
from 10ng/mL to 50 ng/mL.
Jirka 2001. WMD Protective Clothing for the First Responder. EMS Magazine .
Available at http://www.emsmagazine.com/newsarticles/protclothing.html.
Kadar et al. 2003. A topical skin protectant against chemical warfare agents. Isr Med
Assoc J. 5(10):717-9.
BACKGROUND: Sulfur mustard and VX are potent chemical warfare agents that
penetrate rapidly through the skin, causing severe prolonged injuries and sometimes
death. OBJECTIVES: To develop a topically applied pretreatment that will act as a
barrier and prevent the absorption of these agents through the skin, reducing morbidity
and saving life. METHODS: Several formulations were developed and tested in
preclinical animal studies in pigs. The protecting cream was applied as a single
application (0.5-1 ml/100 cm2) prior to exposure (10 minutes to 12 hours) to sulfur
mustard or VX. Assessment of sulfur mustard-induced skin damage was based on clinical
and histologic evaluations. When tested against VX, clinical signs and blood
cholinesterase activity were monitored. At the final stage of development, safety studies
were conducted in animals and in human volunteers. RESULTS: The formulation that
gave the best results, coded IB1 (under patent application), provided significant
protection against a 1 hour exposure to sulfur mustard (droplets or vapor). All the pigs
pretreated with IB1 cream survived a 1-4 hour challenge of 2xLD50 VX and did not
exhibit any overt clinical signs. Protection was exhibited even when the cream was
applied 12 hours (single application) prior to exposure. IB1 was found to be non-irritating
in animals and humans. No adverse effects were found in a Phase I clinical study in
young healthy volunteers when the cream was applied to around 20% of the skin surface
(results presented elsewhere). CONCLUSIONS: IB1 cream has been shown to be a safe
and effective topical skin protectant against the chemical warfare agents sulfur mustard
and VX.
Koplovitz et al. 1992. Reduction by pyridostigmine pretreatment of the efficacy of
atropine and 2-PAM treatment of sarin and VX poisoning in rodents. Fundam Appl
Toxicol. 18(1):102-6.
This study concerned the effect of pyridostigmine pretreatment on (a) the antidotal
efficacy of atropine and 2-PAM in sarin, tabun, and VX poisoning in mice and guinea
pigs and on (b) the oxime-induced reactivation of VX-inhibited whole blood
acetylcholinesterase (AChE) of guinea pigs. One hour prior to organophosphate (OP)
challenge with sarin, tabun, or VX, animals were given oral doses of pyridostigmine to
induce approximately 30 and 60% inhibition of whole blood AChE; controls received
vehicle. Mice were challenged im and guinea pigs sc with the OP compounds. Treatment
with atropine (11.2 mg/kg to mice; 32 mg/kg to guinea pigs) plus 2-PAM (25 mg/kg) was
given im at 10 sec postchallenge in mice and 1 min postchallenge in guinea pigs. In the
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
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31
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axonopathies, and of nerve crush. The phenomenon has been called promotion and has so
far been observed in experimental animals only.
Brain Res. 1987 Dec 1;435(1-2):123-37
Munro et al. 1994. Toxicity of the organophosphate chemical warfare agents GA, GB,
and VX: implications for public protection. Environ Health Perspect 102:18-38.
Available at http://ehp.niehs.nih.gov/members/1994/102-1/munro-full.html .
The nerve agents, GA, GB, and VX are organophosphorus esters that form a major
portion of the total agent volume contained in the U.S. stockpile of unitary chemical
munitions. Congress has mandated the destruction of these agents, which is currently
slated for completion in 2004. The acute, chronic, and delayed toxicity of these agents is
reviewed in this analysis. The largely negative results from studies of genotoxicity,
carcinogenicity, developmental, and reproductive toxicity are also presented. Nerve
agents show few or delayed effects. At supralethal doses, GB can cause delayed
neuropathy in antidote-protected chickens, but there is no evidence that it causes this
syndrome in humans at any dose. Agent VX shows no potential for inducing delayed
neuropathy in any species. In view of their lack of genotoxcity, the nerve agents are not
likely to be carcinogens. The overreaching concern with regard to nerve agent exposure is
the extraordinarily high acute toxicity of these substances. Furthermore, acute effects of
moderate exposure such as nausea, diarrhea, inability to perform simple mental tasks, and
respiratory effects may render the public unable to respond adequately to emergency
instructions in the unlikely event of agent release, making early warning and exposure
avoidance important. Likewise, exposure or self-contamination of first responders and
medical personnel must be avoided. Control limits for exposure via surface contact of
drinking water are needed, as are detection methods for low levels in water or foodstuffs.
National Research Council (US) 1999. Subcommittee on Chronic Reference Doses for
Selected Chemical-Warfare Agents. Review of the U.S. Army's Health Risk Assessments
for Oral Exposure to Six Chemical-Warfare Agents Appendix D, National Academy
Press. Available at http://books.nap.edu/books/0309065984/html/197.html - pagetop .
Newmark 2004. Therapy for nerve agent poisoning. Arch Neurol. 61(5):649-52.
Neurologists need to familiarize themselves with nerve agents, the most toxic of the
chemical warfare agents. Their mode of action lies within the nervous system, and
nonneurologists will look to neurologists for expert advice on therapy. These agents
cause rapid-onset cholinergic crisis amenable to prompt treatment with specific antidotes.
Experience on the battlefield and in terrorist attacks demonstrates that therapy saves
lives.
Page 2003. Long-term health effects of exposure to sarin and other anticholinesterase
chemical warfare agents. Mil Med. 168(3):239-45.
In a telephone survey of 4,022 military volunteers for a 1955-1975 program of
experimental exposures to chemical agents at Edgewood, Maryland, the current health of
those exposed to anticholinesterase agents was compared with that of men exposed to no
active chemicals (no chemical test) and to two or more other types of chemical agents
(other chemical tests). The survey posed questions about general health and about
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
34
neurological and psychological deficits. There were only two statistically significant
differences: volunteers in anticholinesterase agent tests reported fewer attention problems
than those in other chemical tests and greater sleep disturbance than those in no chemical
tests. In contrast, volunteers who reported exposure to civilian or military chemical
agents outside of their participation in the Edgewood program reported many statistically
significant adverse neurological and psychological effects, regardless of their
experimental exposure. In this study, the health effects of self-reported, nonexperimental
exposure, which are subject to recall bias, were greater than the health effects of
experimental exposure.
Rao et al. 1987. Noncompetitive blockade of the nicotinic acetylcholine receptor-ion
channel complex by an irreversible cholinesterase inhibitor. J Pharmacol Exp Ther.
240(1):337-44
Abstract:
Interactions of O-ethyl S-[2-(diisopropylamino)ethyl]methylphosphonothioate (VX), an
irreversible, organophosphorus, anticholinesterase (anti-ChE) agent, with the nicotinic
acetylcholine receptor-ion channel complex (AChR) of the frog Rana pipiens were
investigated using electrophysiological techniques. At low concentrations (0.1-0.5
microM) of VX, typical effects due to cholinesterase (ChE) inhibition, such as
potentiation of indirect muscle twitches as well as increases in the peak amplitude and
decay time constant (tau EPC) of end-plate currents (EPC), were observed. At
concentrations greater than or equal to 1.0 microM, VX produced opposite effects. The
indirectly elicited muscle twitches and EPC peak amplitude were depressed with an IC50
of about 33 microM. tau EPC was reduced, and at a higher concentration of 100 microM,
VX split the decays into faster and slower components. Similar results were also obtained
with the amplitude and decays of miniature end-plate currents (MEPC). However,
although the MEPC peak amplitude and tau MEPC were not decreased to levels below
control values, EPC peak amplitude (but not its tau EPC) was markedly depressed
beyond the control values, in a concentration-dependent manner. The fact that nerve
action potential-evoked events were more affected than the spontaneous MEPCs
suggested an interference with the depolarization-evoked release process. Indeed, VX
caused a reduction of the quantal content and, in addition, induced a significant increase
in the frequency of MEPCs. All these effects, except the anti-ChE activity, were
reversible upon wash. The results from both EPC fluctuation analysis and single channel
recordings disclosed a concentration-dependent shortening of the channel open times
without change in single channel conductance.
Reutter et al. 1999. Evaluation of Airborne Exposure Limits for VX: Worker and
General Population Exposure Criteria. ECBC-TR-074. Edgewood Chemical and
Biological Center, Aberdeen Proving Ground, Md., December 1999 NTIS Order No.
ADA 375312.
Existing occupational airborne exposure limits (now referred to as worker population
limits or WPLs) and general population limits airborne limits (now referred to as
general population limits or GPLs) were reviewed and recalculated using current risk
assessment methods and two sets of data not considered in previous estimates. The
newer data resulted in estimated WPLs and GPLs lower than existing values. However
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
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the quality of both sets of data was such that there was not sufficient confidence to select
either as a critical study. Overall the quality and quantity of data for VX are less than
desirable. In addition no chronic studies have been done. Given this, it was decided to
develop the exposure limits relative to GB. A potency ratio of 10 was selected, based
upon relative potencies of GB and VX in producing miosis. (It was noted, however, that
unlike GB, VX vapor is a percutaneous hazard, and the relative potency ratio for
percutaneous effects is about 100.) Based upon the miosis potency ratio, the existing
WPL for VX (0.00001 mg/m3) was deemed adequately protective. However, the
existing GPL was not, and a concentration of 0.0000003 mg/m3 is recommended. The
existing immediately dangerous to life or health (IDLH) exposure level for occupational
workers was recalculated relative to that for GB. A value of 0.01 mg/m3 is
recommended. A short-term exposure limit (STEL), for workers, was developed reative
to that for GB. The recommended value is 0.00004 mg/m3, for up to four 15-minute
exposures per day. Similarly, relative to those for GB, acute exposure guideline levels
(AEGL-1) were developed for the general population for exposure durations of 30
minutes, 60 minutes, and four hours. The recommended concentrations are 0.00024
mg/m3, 0.00012 mg/m3, and 0.00003 mg/m3.
Robineau 1987. Cardiac abnormalities in rats treated with methylphosphonothiolate.
Toxicol Appl Pharmacol. 87(2):206-11.
Cardiac toxicity of methylphosphonothiolate (MPT), an organophosphorus compound,
has been investigated in the rat. Subcutaneous injection of MPT (12 micrograms/kg body
wt) induced cardiac arrhythmias, the occurrence of which was significantly more frequent
than in the control group. Death rate among MPT-treated animals appeared to be in
relationship with cardiac arrhythmias. Plasma nonesterified fatty acid concentrations
increased in MPT-poisoned rats. cAMP and cGMP contents in myocardial tissue were
unchanged 150 min after MPT administration, as compared with control. Similarly, no
change has occurred in high energy compound levels.
Robineau et al. 1987. Effects of an organophosphorus compound on cardiac rhythm and
hemodynamics in anaesthetized and conscious beagle dogs. Toxicol Lett 37:95-102.
Cardiac toxicity of S-(2-diisopropylaminoethyl)-O-ethylmethyl phosphonothiolate (VX)
has been investigated in the dog. Conscious or open-chest anaesthetized animals were
subcutaneously injected with VX (1.5, 3.0 or 6.0 micrograms/kg b.w.). Blood
cholinesterase activity decreased to 60%, 20% and 18% respectively of initial values.
Only in the 6.0 micrograms/kg-treated group, heart rate, arterial and left intraventricular
pressures and contractility index slightly but significantly decreased. In some dogs,
treated with either 3.0 micrograms/kg or 6.0 micrograms/kg b.w. of VX, the
electrocardiogram was changed: the Q-T interval was lengthened and arrhythmias
(atrioventricular blocks, ventricular premature complexes. 'Torsade de pointe') were
observed. Plasma non-esterified fatty acid concentrations were identical in control and
VX-poisoned dogs. This study shows that, besides the expected cardiac effects resulting
from muscarinic stimulation, VX can affect ventricular function through a yet unknown
mechanism.
36
Robineau et al. 1991. An organophosphorus compound, VX, selectively inhibits the rat
cardiac Na+,K(+)-ATPase alpha 1 isoform. Biochemical basis of the cardiotoxicity of
VX. FEBS Lett. 281(1-2):145-8.
Serine-specific reagents, anticholinesterase organophosphorus compounds like Vx
provoke, in the micromolar range, digitalis-like ventricular arrhythmias of noncholinergic origin in rodent hearts. The sensitivities of the two rat cardiac Na+,K(+)ATPase isoforms (alpha 1 and alpha 2) to Vx (0.1-100 microM) were measured in
sarcolemma vesicles. At 1 microM Vx, the inhibition of the total activity averaged 18%
but never exceeded 75% with 100 microM. When the alpha 2 isoform activity was
inhibited by 0.1 microM ouabain, alpha 1 was 35% inhibited by 1 microM Vx, i.e. a 16
+/- 4% inhibition of the total activity. The cardiac alpha 1 being related to the digitalisinduced toxicity, its selective inhibition by a micromolar dose of Vx fully accounts for
the cardiotoxicity of Vx. Inasmuch as Vx had no effect on the rat kidney alpha 1,
differentially inactivated the cardiac isozymes and specifically reacted with serine
residues, the putative binding-site(s) of the organophosphorus compound on the Na+K(+)-ATPase molecules has been considered.
Sidell et al. 1974. The reactivatibility of cholinesterase inhibited by VX and sarin in
man. Toxicol. Appl. Pharmacol.27(2): 241-252.
The cholinesterase inhibitors VX (S,S-(2-diisopropylaminoethyl) O-ethyl methyl
phosphonothiolate) and sarin (isopropyl methyl phosphonofluoridate) were given to
normal subjects. An iv dose of 1. 5 mug/kg and an oral dose of 4.0 mug/kg of VX caused
a 75% inhibition of erythrocyte cholinesterase. The oxime 2-pyridinium aldoxime
methochloride (pralidoxime, 2-PAMCl) was administered at varying times and over a
range of doses to these subjects who had received VX and also to subjects who had
received sarin. It was found that the RBC-ChE inhibited by VX spontaneously reactivates
much faster than that inhibited by sarin. VX-inhibited RBC-ChE ages very little and is
amenable to oxime reactivation for as long as 48 hr; the dose of oxime necessary to
reactivate VX-inhibited RBC-ChE is less than that needed to reactivate sarin-inhibited
enzyme.
Sidell 1997. Nerve Agents. In Medical Aspects of Chemical and Biological Warfare.
Chapter 5. Eds. Sidell FR, Takafuji ET, Franz DR.. Office of the Surgeon General, Dept.
of the Army, United States of America.
Available at http://www.bordeninstitute.army.mil/cwbw/default_index.htm.
Sidell et al. 1997. Longterm Health Effects of Nerve Agents and Mustard. In Medical
Aspects of Chemical and Biological Warfare. Chapter 8. Eds. Sidell FR, Takafuji ET,
Franz DR.. Office of the Surgeon General, Dept. of the Army, United States of America.
Available at http://www.bordeninstitute.army.mil/cwbw/default_index.htm.
Smart 1997. History of Chemical and Biological Warfare: An American Perspective. In
Medical Aspects of Chemical and Biological Warfare. Eds. Sidell FR, Takafuji ET, Franz
DR. 1997. Office of the Surgeon General, Dept. of the Army, United States of America.
Available at http://www.bordeninstitute.army.mil/cwbw/default_index.htm.
Contract No. IOM-2794-04-001
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Somani et al. 2001. Low-Level Nerve Agent Toxicity under Normal and Stressful
Conditions. In Chemical Warfare Agents: Toxicity at Low Levels. Chapter3. Eds. Somani
SM, Romano JA. CRC Press Boca Raton.
Special Assistant to Undersecratary of Defense for Gulf War Illnesses, Medical
Readiness, and Miltary Deployment. 2004. Project Shipboard Hazard and Defense
(SHAD) Flower Drum Phase II available at
http://deploymentlink.osd.mil/pdfs/flower_drum_phase_ii.pdf
Special Assistant to Undersecratary of Defense for Gulf War Illnesses, Medical
Readiness, and Miltary Deployment. 2004. Project Shipboard Hazard and Defense
(SHAD) Fearless Johnny available at
http://deploymentlink.osd.mil/pdfs/fearless_johnny.pdf .
Tsuchihashi et al. 1998. Identification of Metabolites of Nerve Agent VX in Serum
Collected from a Victim. J. Anal. Toxicol. 22:383-388.
A human serum sample collected from a victim of the Osaka VX incident was analyzed
according to our developed technique for metabolites of VX. Gas chromatography-mass
spectrometry (GC-MS) in full-scan electron impact and chemical ionization modes were
used, and, for more reliable confirmation, GC-MS-MS was also employed. In the serum
sample, both ethyl methylphosphonic acid and 2-diisopropylamino-ethyl)methyl sulfide
were detected. These results indicated that the techniques using GC-MS and GC-MS-MS
were applicable to biological samples such as serum. These results also provide the first
documented, unequivocal identification of the specific metabolites of VX in victims
serum and, furthermore, clarify a part of the metabolic pathway of VX in the human
body.
Tuovinen 2004. Organophosphate-induced convulsions and prevention of
neuropathological damages. Toxicology. 196:31-9.
Such organophosphorus (OP) compounds as diisopropylfluorophosphate (DFP), sarin and
soman are potent inhibitors of acetylcholinesterases (AChEs) and butyrylcholinesterases
(BChEs). The acute toxicity of OPs is the result of their irreversible binding with AChEs
in the central nervous system (CNS), which elevates acetylcholine (ACh) levels. The
protective action of subcutaneously (SC) administered antidotes or their combinations in
DFP (2.0 mg/kg BW) intoxication was studied in 9-10-weeks-old Han-Wistar male rats.
The rats received AChE reactivator pralidoxime-2-chloride (2PAM) (30.0 mg/kg BW),
anticonvulsant diazepam (2.0 mg/kg BW), A(1)-adenosine receptor agonist N(6)cyclopentyl adenosine (CPA) (2.0 mg/kg BW), NMDA-receptor antagonist dizocilpine
maleate (+-MK801 hydrogen maleate) (2.0 mg/kg BW) or their combinations with
cholinolytic drug atropine sulfate (50.0 mg/kg BW) immediately or 30 min after the
single SC injection of DFP. The control rats received atropine sulfate, but also saline and
olive oil instead of other antidotes and DFP, respectively. All rats were terminated either
24 h or 3 weeks after the DFP injection. The rats treated with DFP-atropine showed
severe typical OP-induced toxicity signs. When CPA, diazepam or 2PAM was given
immediately after DFP-atropine, these treatments prevented, delayed or shortened the
occurrence of serious signs of poisoning. Atropine-MK801 did not offer any additional
Contract No. IOM-2794-04-001
Health Effects of VX Nerve Agent
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Wetherell et al. 2002. Physostigmine and hyoscine improves protection against the
lethal and incapacitating effects of nerve agent poisoning in the guinea-pig.
Neurotoxicology. 23(3):341-9.
This study is drawn from a work programme aimed at developing improved medical
counter measures for nerve agent poisoning. Guinea-pigs were administered
pyridostigmine (5.1 microg/h) or physostigmine (4.7 microg/h) and hyoscine (1.94
microg/h) for 6 days via a subcutaneously implanted mini osmotic pump. Pyridostigmine
inhibited red cell acetylcholinesterase (AChE) by 44.2 +/- 2.7% and plasma
cholinesterase (ChE) by 29.9 +/- 1.8%. Physostigmine and hyoscine inhibited red cell
AChE by 18.7 +/- 3.7% and plasma ChE by 44.1 +/- 3.1%. On day 6, animals were
challenged with a lethal dose of tabun (GA; 125 microg/kg), sarin (GB; 51.2 microg/kg),
soman (GD; 31.2 microg/kg), GF (50 microg/kg) or VX (11.25 microg/kg) administered
by the subcutaneous route. Animals were closely observed for signs of poisoning. The
time to the onset of signs of poisoning was similar for all the agents except for VX, which
showed a delay compared to the other agents. Following pretreatment with either
pyridostigmine or physostigmine and hyoscine most animals survived for 2-3 h following
nerve agent administration. In contrast, only physostigmine and hyoscine prevented or
reduced the duration of the signs of incapacitation and the temperature drop produced by
all the agents. Pyridostigmine-pretreated animals showed little or no recovery from
incapacitation prior to death. Physostigmine and hyoscine pretreatment provided
statistically (P < 0.05) better protection against GB, GD and VX lethality (24 h) than
pyridostigmine pretreatment and better protection against GA and GF lethality.
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