More than 200 individuals from U.S. government agencies as well as officials and clinicians from Maryland and other states had the opportunity to hear first responders, physicians, and defense researchers from the United Kingdom detail their government's response to the chemical weapon attack that occurred in Salisbury in March 2018 and the subsequent exposure in June of two individuals in nearby Amesbury during a two-day symposium, held February 21-22. The meeting was sponsored by the Office of the Deputy Assistant Secretary of Defense for Chemical and Biological Defense and the Joint Program Executive Office for Chemical, Biological, Radiological and Nuclear Defense and was hosted by the U.S. Army Medical Research Institute of Chemical Defense in its Sidell auditorium, at Aberdeen Proving Ground.

The attack on the former Russian spy Sergei Skripal and his daughter, Yulia, was particularly alarming because the nerve agent used was Novichok and not one of the traditional nerve agents, such as sarin and VX. The attack was not only a criminal incident but also a case of international terrorism with potential political implications, all factors that impacted patient care, its management, and the scientific investigation. Fortunately, the Skripals survived, as did two other exposed individuals; one of the Amesbury victims, however, died.

As USAMRICD Commander Col. Denis Descarreaux said in his opening remarks, "Victims of a non-traditional chemical attack will present to hospitals, not laboratories. Although we must be careful not to extrapolate too broadly the specifics of this limited experience with one particular agent, the experience of our colleagues in the U.K. has a great deal to teach us not only in terms of acute and in-hospital medical management but also in terms of local and national health care response."

David Williams, senior medical portfolio/acquisition manager for JPEO-CBRND, opened the meeting each day and reviewed the JPEO-CBRND's Integrated Layered Defense protection framework and stressed the importance of the health care providers (from medic to physician), who have field operational experience, as well as the bench scientists, being fully invested in the development of the Warfighters' CBRN Medical Countermeasure Requirements.

The first day of briefings focused on the clinical presentations and continuum of care as well as the public health response. Dr. Ian Jenkins, one of the physicians at the hospital, the Salisbury National Health Service Foundation Trust, and Dr. Steve Emmett, from the U.K.'s Defence Science and Technology Laboratory, began by providing the timeline that resulted in first responders finding the Skripals seriously ill on a park bench in an area known for drug activity. Given that and the symptoms they were observing, the first responders treated the Skripals for a drug overdose.

As if taking the audience on "grand rounds," Jenkins and Emmett detailed the course of the patients' illnesses and their responses to various treatments. Jenkins described the growing suspicion that the symptoms "suggested a cholinergic toxidrome," that is, inhibition of the enzyme cholinesterase, which is indicative of exposure to an organophosphate, such as a nerve agent. Their thought, according to Jenkins, was, "how do we test for that"?

Scientific support from a number of organizations, including DSTL, helped answer that question, but the involvement of a toxic chemical introduced a host of unusual issues for the hospital, such as decontamination of not only the patients but also the medical equipment used to perform tests on them.

While the diagnostic process was taking place, the local police, having identified the victims, wanted the intensive care unit closed for security reasons, and one of the police officers who had been to the Skripals' home as part of the investigation arrived at the emergency room exhibiting similar symptoms; he would also be cared for in the ICU.

Confirmation of nerve agent poisoning, identification of the particular agent, a more targeted course of treatment and a long recovery for the patients followed. Four months later, the hospital staff relived the scenario when two individuals from Amesbury were accidently exposed to the same nerve agent.

Dr. Christine Blanshard, medical director and deputy chief executive officer at the Salisbury NHS Foundation Trust, provided a briefing on leadership from the hospital management's aspect of the chemical attack. Blanshard detailed the challenges faced in working with 25 other organizations on a national interagency response to such a highly sensitive incident.

Additionally, there were hoaxes to deal with, harassment on social media and intense media spotlight with constant attempts by the press to get information. During the second incident, media interviews of friends and family members of the Amesbury couple further complicated press relations. Numerous experts came forward, with some offering assistance and others providing conflicting information to the news media.

The March chemical attack was the longest running incident in NHS history: the final debrief took place at the end of June. Throughout those four months, the hospital had to continue to serve the needs of the region and provide emergency and scheduled care to the local population. The situation taxed the hospital staff, and one of the long-term consequences that will be studied is the psychological effects of the two incidents on the staff.

Dr. John Simpson, of Public Health England, closed the first day with a discussion on the role of PHE in the attack. PHE was responsible for risk assessment and mitigation, for keeping the public informed without causing panic and for increasing the knowledge base of the basics of CBRN for the U.K. health system. They addressed environmental contamination and recovery, the transferability of the agent, and tracing individuals who may have come in contact with the agent. Simpson said it was about "providing the right information in the right way" and that in general "the public is sensible ... [and] will listen to authorities."

"I'm filled with admiration and respect for the work of the presenters, but also for the hospital staff," said, Col. Thomas Frank, chief of USAMRICD's Chemical Casualty Care Division, before summing up day one discussions.

Frank described the outcome of the chemical attack as both a "good news story" and a "cautionary tale": the personal protective equipment provided the necessary protection and the current medical countermeasures worked, but the amount of resources consumed for so few patients was extensive, indicating how potentially crippling a mass casualty scenario could be.

The second day of briefings looked at the non-healthcare and whole-of-government response, beginning with an overview of the Salisbury chemical weapon attack event from the perspective of DSTL, which was presented by Dr. Mark Fulop, senior representative in the laboratory's Office of Chemical and Biological Research. Fulop's briefing indicated the scale of their support and described how DSTL contributed to the investigation. He was followed by Dr. Tim Atkins, senior scientific advisor for the event. Atkins discussed the U.K.'s overarching guidelines for, and agency responsibilities in, responding to emergencies and how those were applied in the two chemical agent exposure events. Specifically, he discussed how support in the areas of science and technology is provided.

Dr. Cerys Rees, also a senior scientific advisor at DSTL, delved into the scientific portion of the investigation. Rees described the analyses to identify the agent and testing of numerous samples from a variety of sources to determine contamination as well as to confirm or discount human exposures.

Fulop finished out the discussions with an overview of the Chemical/Biological Response Team and the tactical support members provided in the Salisbury and Amesbury incidents. He also reviewed the impact of science on the investigation.