At least 80 people have been killed in a suspected chemical attack on the rebel-held town of Khan Sheikhoun in north-western Syria.
Hundreds suffered symptoms consistent with reaction to a nerve agent after what the opposition and Western powers said was a Syrian government air strike on the area on Tuesday morning.
The Syrian military denied using any chemical agents, while its ally Russia said an air strike hit a rebel depot full of chemical munitions.
Activists and witnesses say warplanes attacked Khan Sheikhoun, about 50km (30 miles) south of the city of Idlib, early on Tuesday, when many people were asleep.
Mariam Abu Khalil, a 14-year-old resident who was awake, told the New York Times that she had seen an aircraft drop a bomb on a one-storey building.
The explosion sent a yellow mushroom cloud into the air that stung her eyes. “It was like a winter fog,” she said. She sheltered in her home, but recalled that when people started arriving to help the wounded, “they inhaled the gas and died”.
Hussein Kayal, a photographer for the pro-opposition Edlib Media Center (EMC), told the Associated Press that he was awoken by the sound of an explosion at about 06:30 (03:30 GMT). When he reached the scene, there was no smell, he said. He found people lying on the floor, unable to move and with constricted pupils.
Mohammed Rasoul, the head of a charity ambulance service in Idlib, told the BBC that he heard about the attack at about 06:45 and that when his medics arrived 20 minutes later they found people, many of them children, choking in the street.
The Union of Medical Care and Relief Organisations (UOSSM), which funds hospitals in rebel-held Syria, said three of its staff in Khan Sheikhoun were affected while treating patients in the streets and had to be rushed to intensive care.
Victims experienced symptoms including redness of the eyes, foaming from the mouth, constricted pupils, blue facial skin and lips, severe shortness of breath and asphyxiation, it added.
A Medecins Sans Frontieres (MSF) medical team supporting the Bab al-Hawa hospital, near the Turkish border, confirmed similar symptoms in eight patients brought there from Khan Sheikhoun.
How many victims?
Rescue workers and opposition activists posted photos and videos on social media that showed victims exhibiting the symptoms described by doctors, as well as many people who had died.
The EMC posted photos showing what appeared to be at least seven dead children in the back of a pick-up truck. There were no visible traumatic injuries.
Another photo published by the group showed the bodies of at least 14 men, women and children on a street outside a hospital in Khan Sheikhoun.
The opposition-run health directorate in Idlib province – which is almost entirely controlled by rebel fighters and al-Qaeda-linked jihadists – says at least 84 people were killed, including 27 children and 19 women. Another 546 people were injured.
The Syrian Observatory for Human Rights, a UK-based monitoring group, put the death toll at 86 and said it was likely to rise, with many of the injured in a serious condition in hospital.
It was also not immediately clear whether anyone was killed when Khan Sheikhoun’s main hospital was struck by a rocket on Tuesday afternoon.
The source of the projectile was not clear, but the EMC said warplanes had targeted clinics and the headquarters of the Syria Civil Defence, whose rescue workers are known as the White Helmets.
What were they exposed to?
The World Health Organization said on Wednesday that the likelihood of a chemical being responsible was “amplified by an apparent lack of external injuries reported in cases showing a rapid onset of similar symptoms, including acute respiratory distress as the main cause of death”.
“Some cases appear to show additional signs consistent with exposure to organophosphorus chemicals, a category of chemicals that includes nerve agents.”
The Organisation for the Prohibition of Chemical Weapons (OPCW) expressedserious concern about the reports and said a fact-finding mission was “in the process of gathering and analysing information from all available sources”.
The OPCW will not be able to confirm anything until samples are tested at an accredited laboratory, but a doctor at a hospital in the town of Sarmin who treated some of the casualties believes it was the nerve agent Sarin.
“All the patients had the same symptoms – difficulty in breathing, weakness,” Dr Abdulhai Tennari told the BBC. “They had very huge secretions in their respiratory tracts, which induced suffocation.”
He noted that when the most serious cases were given an antidote for Sarin poisoning, atropine, their conditions became stable and they survived.
MSF said the patients’ symptoms were “consistent with exposure to a neurotoxic agent such as Sarin”. Its medical teams also reported that victims smelled of bleach, suggesting they had been exposed to chlorine as well.
On Thursday, Turkey’s health ministry said the initial results of post mortems carried out on three victims under WHO supervision suggested that they “were exposed to a chemical substance (Sarin)”. They suffered “pulmonary oedema [build-up of fluid], increase in the lung weight and blood in the lungs”, it added.
What does the Syrian government say?
A Syrian military statement published by state media categorically denied the use of “any chemical or toxic substance” in Khan Sheikhoun on Tuesday, adding that the military “has never used them, anytime, anywhere, and will not do so in the future.”
Russia, which has carried out air strikes in support of President Assad since 2015, meanwhile said the Syrian air force had struck Khan Sheikhoun “between 11:30am and 12:30pm local time” on Tuesday, but that the target had been “a large terrorist ammunition depot” on its eastern outskirts.
“On the territory of the depot, there were workshops which produced chemical warfare munitions,” it added, without providing any evidence. “Terrorists had been transporting chemical munitions from this largest arsenal to the territory of Iraq.”
The ministry said the chemical munitions had also been used during the final stages of the battle for control of the northern Syrian city of Aleppo last autumn, asserting that the symptoms of the victims were “the same”.
Is Russia’s explanation credible?
Hamish de Bretton-Gordon, a former commanding officer of the British Armed Forces Joint Chemical Biological Radiological Nuclear (CBRN) Regiment, said it was “pretty fanciful”.
“Axiomatically, if you blow up Sarin, you destroy it,” he told the BBC.
Experts say the explosion resulting from an air strike on a chemical weapons facility would most likely incinerate any agents. Sarin and other nerve agents are also usually stocked in a “binary manner”, which means they are kept as two distinct chemical precursors that are combined just before use, either manually or automatically inside a weapon when launched.
“It’s very clear it’s a Sarin attack,” Mr de Bretton-Gordon added. “The view that it’s an al-Qaeda or rebel stockpile of Sarin that’s been blown up in an explosion, I think is completely unsustainable and completely untrue.”
He also noted that chlorine was the only chemical believed to been used in attacks in Aleppo over the past year.
A recent report by Human Rights Watch said government helicopters had dropped bombs containing chlorine on rebel-held areas of Aleppo on at least eight occasions between 17 November and 13 December, killing nine civilians.
Hasan Haj Ali, commander of the Free Idlib Army rebel group, called Russia’s claim a “lie” and said rebel fighters did not have the capability to produce nerve agents.
The UK’s representative to the UN, Matthew Rycroft, also told the Security Council that his country had seen nothing to suggest that any non-state actors in Syria had the sort of chemical weapons that would have been consistent with the symptoms.
The French envoy, Francois Delattre, meanwhile said there was “no fire” after the air strike, even though a strike on an ammunition depot “would have caused a fire”.
It was also not clear why there was five hours’ difference between the time of the strike reported by multiple witnesses and that stated by Russia.
Moscow’s short account gave no evidence for its suggestion that a group was sending chemical weaponry to Iraq. The so-called Islamic State group, which has used sulphur mustard in Syria and Iraq, is not present in Khan Sheikhoun.
What is Sarin?
Sarin is highly toxic and considered 20 times as deadly as cyanide.
As with all nerve agents, Sarin inhibits the action of the acetylcholinesterase enzyme, which deactivates signals that cause human nerve cells to fire. This blockage pushes nerves into a continual “on” state. The heart and other muscles – including those involved in breathing – spasm. Sufficient exposure can lead to death via asphyxiation within minutes.
Sarin is almost impossible to detect because it is a clear, colourless and tasteless liquid that has no odour in its purest form. It can also evaporate and spread through the air.
Has Sarin been used in Syria before?
The Syrian government was accused by Western powers of firing rockets filled with Sarin at several rebel-held suburbs of the capital Damascus in August 2013, killing hundreds of people.
President Bashar al-Assad denied the charge, blaming rebel fighters, but he did subsequently agree to destroy Syria’s declared chemical arsenal.
Despite that, the OPCW and UN have continued to document the use of chemicals in attacks.
A joint investigation concluded in October that government forces had used chlorine as a weapon at least three times between 2014 and 2015. It also found Islamic State militants had used the blister agent sulphur mustard.