Long-term Health Outcomes Among Survivors Exposed to Sulfur Mustard in Iran

Abstract

IMPORTANCEThe prevalence and severity of long-term health complications after exposure to sulfur mustard are unknown.OBJECTIVE To investigate the long-term health outcomes among survivors exposed to sulfur mustard during the Iran-Iraq War. DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study, late-onset health complications of 64 190 Iranian survivors exposed to sulfur mustard during the Iran-Iraq War from 1980 to 1988 were investigated using descriptive statistics. Data involving affected organs and symptom severity were extracted from the Veterans and Martyr Affair Foundation (VMAF) database from 1980 to 2019. Assessments were conducted across 3 groups depending on whether survivors were (1) evacuated and admitted (EA) to a hospital; (2) not evacuated or admitted (NEA) to a hospital; or (3) evacuation or admission status was not documented. EXPOSURES Analysis of chronic symptom severity following exposure to sulfur mustard. MAIN OUTCOMES AND MEASURESMild, moderate, or severe rankings of symptoms in lungs, eyes, and skin of survivors exposed to sulfur mustard using data from the VMAF database. RESULTSOf 64 190 chemical survivors registered in the VMAF database, 60 861 met the inclusion criteria. Of the included survivors, 98.0% were male, and the mean (SD) age was 23.5 (7.7) years.Most survivors (53 675 [88.2%]) had no symptoms or mild lesions, and 7186 survivors (11.8%) had moderate or severe complications. Moderate to severe lung (6540 [10.7%]), eye (335 [0.6%]), or skin (725 [1.2%]) injuries were documented in the exposed population. The proportion of moderate plus severe late complications in eyes was 3 times as high in male survivors compared with female survivors (0.6% [95% CI, 0.53%-0.65%] vs 0.2% [95% CI, 0.09%-0.73%]; P < .001), whereas dermal complications were significantly more common in female survivors (3.9% [95% CI, 2.92%-5.11%] vs 1.14% [95% CI, 1.06%-1.23%]; P < .001). Mild lung lesions were more prevalent in the NEA group than in the EA group (73.9% [95% CI, 73.4%-74.4%] vs 11.0% [95% CI, 10.6%-11.3%]; P < .001). In the NEA group, 83.2% (n = 23 866) developed lung injuries that were mostly mild or moderate, whereas 77% (n = 24 766) of the EA group did not develop lung injuries (P < .001). CONCLUSIONS AND RELEVANCEThe present study found sex differences in the frequencies of eye and skin complications following sulfur mustard exposure, and lung complications were more prevalent years after sulfur mustard exposure than soon after exposure. Mild lung lesions were observed more frequently among sulfur mustard-exposed survivors who had not been evacuated or hospitalized than among those who had been evacuated or hospitalized. These differences may be due to physiological response or dose of exposure. Close monitoring over an extended period may be required for detection of late pulmonary complications in individuals exposed to sulfur mustard.

Mortality rate of people exposed to Mustard Gas during Iran-Iraq war in Sardasht, Iran: a 32 years retrospective cohort study

“…VMAF is a legal authority in Iran that provides pension and health services to war survivor. This foundation registers all survivors of war and then regularly provides long-term care services to them and their families by maintaining excellence in health care services through professional collaboration [ 7 , 9 ]. Therefore, the inclusion criterion was the approval of the VMAF of Iran to contact of the persons with the chemical agent of MG and the exclusion criterion included the occurrence of premature death.…”

“…Based on this protocol, the complications in these people were divided into four categories: no symptoms, mild, moderate and severe symptoms. The panel included pulmonologists, psychiatrists, neurologists, ophthalmologists, dermatologists, cardiologists, forensic specialists and nephrologists who reviewed the relevant documents and evidence and categorized them [ 7 ]. Definitions of late complications in lung, skin and eye are as follow: Lungs: Categorization of complications in lung following MG exposure were defined using spirometry results of forced expiratory volume in the first second (FEV1) as follows: no symptoms, FEV1 higher than 80%; mild, FEV1 higher than 70% but lower than or equal to 80%; moderate, FEV1 higher than 50% but lower than or equal to 70%; and severe, FEV1 lower than or equal to 50% with normal arterial blood gas or severe tracheabronchomalacia [ 7 , 10 ].…”

“…The use of MG as a chemical weapon in war has so far caused hundreds of thousands of people to be exposed to small or large amounts of this agent in acute form. In other words, since the first use of MG as a chemical weapon by the German army in 1917 in the war against Canadian and French troops, this agent has been repeatedly used in various wars against different countries such as Iran in the 8-years war between Iran and Iraq which has caused injury, complications and death to military and civilian people [ 6 , 7 ].…”

Nano-silver functionalized spherical activated carbon with enhanced dipropyl sulfide adsorption capacity and antibacterial properties

“…From 1980 through 1988, sulfur mustard (HD) was employed as a chemical warfare agent in the Iran-Iraq War. 1 Anthrax terrorist attacks and castor toxin events happened in the United States between 2001 and 2004. 2 Despite the establishment of the Biological Weapons Convention (BWC) and the Biological and Toxin Weapons Convention (BTWC) in recent years, certain governments have continued to develop, store, and use biochemical warfare agents, which makes biochemical terrorist attacks a potential threat.…”

Exposure to sulfur mustard increases the risk for mortality in patients with COVID-19 infection: A cohort study

“…It is believed that thousands of unprotected people living in Iran, Iraq, and Syria have been exposed to SM [ 12 , 13 ]. Late in the course of the disease, SM exposure (SME) is associated with pulmonary complications (Mustard lung) such as asthma, emphysema, chronic bronchitis, obliterative bronchiolitis syndrome, chronic obstructive pulmonary disease, and tracheobronchomalacia [ [14] , [15] , [16] , [17] , [18] , [19] ]. Other long-term effects of SME include cancer, hematologic, immunological, neuropsychiatric, and reproductive problems [ 12 , [20] , [21] , [22] ].…”