“Although a focus on trauma response and humanitarian care is essential for the ongoing Russia-Ukraine war, recent posturing by Russian leadership indicates that radiological or nuclear weapons could be used to defend illegally annexed territories in Ukraine. This situation necessitates readiness for nonconventional warfare threats, which include chemical, biological, radiological, nuclear, and explosives (CBRNE) attacks. CBRNE preparedness has been variable among Ukrainian and European Union member states, which may be called on to detect and respond to potential attacks. Russia or its proxies have used CBRNE weapons in several recent conflicts, and awareness of these risks and mitigation strategies are prudent measures now. Based on these historical ingressions, prioritizing education and equipment for health care professionals to recognize and respond to potential CBRNE threats within Ukraine and bordering countries is essential.

Despite regulations against the use of chemical weapons by the Organisation for the Prohibition of Chemical Weapons (OPCW), Russian chemical weapons research has focused on developing highly potent weaponized organophosphates, or nerve agents. The past decade has seen Russia use these agents in assassination attempts of the Skripals and Alexei Navalny through the introduction of nerve agents in food and clothing. These fourth-generation agents (eg, Novichok, a group of nerve agents) are characterized by their lethality, unconventional routes of poisoning, and long-term environmental persistence. Russia’s connections to Syria also provide insight. The majority of the more than 55 chemical weapon attacks in Syria between 2013 and 2018 involved chlorine gas or the deadly nerve agent sarin in cannisters or combined with bombs dropped from aircraft. Although these events have been attributed to the Syrian government, the close relationship between Syria’s Assad regime and Russia suggests that these indiscriminate strategies could be used in the current conflict.

Weaponized opioids have also been used during the Putin regime. In 2002, Chechen terrorists attacked the Dubrovka Theater in Moscow, resulting in a hostage standoff. In response, Russian special forces instilled a chemical aerosol into the theater’s vents, incapacitating occupants and resulting in 125 deaths. Analysis of clothing from 2 victims demonstrated the presence of remifentanil and carfentanyl, 2 potent opioids, with death likely from poisoning. Although less practical on the battlefield, it is plausible that the Russian military could use similar compounds to cause serious casualties among opposing soldiers, political protestors, or civilians trapped in buildings, hospitals, subways, or bomb shelters.”

Read more on Health and Safety Threats to Ukraine From Nonconventional Weapons: A Clear and Present Danger via JAMA.

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