Date of Report: August 1996
Subject: Non-specific Illnesses in Personnel at the Army Knowledge Network-Combined Arms Center History Office, Fort Leavenworth, Kansas
Personnel at the Army Knowledge Network-Combined Arms Center History Office (History Office) in Fort Leavenworth, Kansas, became sick after working with documents from Haiti, Rwanda, and the Persian Gulf War. These personnel developed flu-like symptoms and chemical sensitivities after handling archival documents.
On March 8, 1995, History Office personnel asked Preventive Medicine (PM) personnel at the U.S. Army Medical Activity (USAMEDDAC), Fort Leavenworth, to evaluate History Office work spaces for possible health hazards. PM personnel speculated that the documents and/or archival boxes underwent fumigation, spraying with insecticides and/or physically contain some other chemical substance. The initial Preventive Medicine analysis revealed elevated levels of carbon dioxide and detected levels of other chemicals (phosphine, phosgene and sulfuric acid) that were capable of causing skin, eye and respiratory tract irritation. The USAMEDDAC PM Industrial Hygienist at Fort Leavenworth initiated testing and did the final analysis of test results. Independent contract laboratories and the United States Army Center for Health Promotion and Preventive Medicine (USACHPPM), Aberdeen, Maryland and USACHPPM Direct Support Activity (DSA)-West conducted sample testing. USACHPPM DSA-West is a detachment located at Fitzsimons Army Medical Center, Aurora, Colorado. Dr. Richard Morris, History Office supervisor, stated the primary document processing room has a 100 percent recirculating air system. This system is a closed loop (no outside/fresh air entering the room), which led to the high carbon dioxide levels. The PM Industrial Hygienist's final analysis was that the History Office suffered from "sick building syndrome" (see technical data below) due to inadequate ventilation. After aeration of the History Office work spaces, all detected chemical levels returned to within acceptable health standards. U.S. Department of Labor Occupational Safety and Health Administration (OSHA) and American Conference of Governmental and Industrial Hygienists (ACGIH) establish these standards.
The PM personnel released their study on October 13, 1995. Subsequently, press reports in the Fort Leavenworth Lamp, November 2, 1995, Leavenworth Times, November 19, 1995, and Kansas City Star, November 21, 1995, discussed the issue of "sick building syndrome" at the History Office.
CHPPM tested document samples handled by, and latex gloves worn by, History Office personnel and found no detectable pesticide levels, although CHPPM did not test for phosphine and phosgene. They also determined that the level of chemicals tested was the same in the boxes and in the room air. If the boxes or documents were the source of these substances, the concentrations in the boxes would have had to have been greater than in the ambient room air. Additionally, if the documents were the source, the gloves worn by personnel would have had a measurable level of these substances. CHPPM does not have any information about exposure-related incidents at any other U.S. Army archival activities.
The Armed Forces Pest Management Board (AFPMB) evaluated the question of possible fumigation of these boxes. AFPMB stated the U.S. Department of Agriculture (USDA) is responsible for the inspection, cleaning, fumigation (if necessary) and release of materials for transport to the continental United States (CONUS). Military personnel, namely entomologists, assist the USDA with identification of insects/vermin that may be present. The USDA, Animal, Plant and Health Inspection Service (APHIS) is responsible for this activity. APHIS personnel state that there is some fumigation of material returning to CONUS. The APHIS fumigation agent of choice is methyl bromide gas, which does not produce phosphine as a degradation product. According to APHIS personnel, no records or knowledge exist concerning fumigation activities on documents returning from the Persian Gulf, Haiti or Rwanda.
The Persian Gulf War Veterans' Illnesses Investigation Team concluded that the boxes and documents are not the source of phosphine or phosgene. This determination relates to the analysis of laboratory results, and phosphine and phosgene levels inside boxes that were not higher than ambient room air. The Investigation Team received information from independent and government sources. Although the origin of trace amounts of phosphine and phosgene is unknown, investigation indicates:
1. Measurable levels were found in all document boxes, including those from Haiti and Rwanda.
2. Documents from Desert Storm were re-boxed before shipment to Fort Leavenworth. No personnel encountered problems relating to phosphine or phosgene exposure in the handling of the original boxes.
3. There is no recorded fumigation of document boxes returned from Operation Desert Shield/Storm.
4. U.S. military personnel do not normally fumigate materials returning to CONUS.
5. The U.S. Department of Agriculture has responsibility for fumigation and other equipment cleaning operations.
6. There is no impregnation of a chemical, which produces phosphine or phosgene as a by-product, of the storage boxes used by the History Office for document archiving.
7. After aeration of work spaces and air-circulation system modification, the cause of History Office personnel illnesses seems to be alleviated.
8. All testing procedures were performed according to established protocols.
9. Proper air quality monitoring is necessary to avoid "sick building syndrome."
10. Other archival/historical offices should routinely monitor air quality and workers' health.
"Sick Building Syndrome" is a condition where there is inadequate filtration of allergens such as chemicals and pollutants (smoke, dust, mold and mildew) from the air. Irritating chemicals exist in carpets, glues/adhesives, upholstery, photocopier fluid, paint, cleaning fluids and paper products. They float throughout the building and can cause allergic reactions in people, such as rashes, coughing and itchy eyes.
Phosphine is a breakdown product of water and the fumigant, aluminum phosphide, and/or the rodenticide, zinc phosphide. Phosphine is a flammable, colorless gas with a fishy or garlic-like odor.
Phosgene is a nonflammable, colorless and highly toxic gas that at low concentrations has the smell of green corn, newly mown hay or decaying fruit. At higher concentrations, phosgene loses its characteristic odor and may become asphyxiating, especially in poorly ventilated spaces. Phosgene can be a by-product of many household chemicals, solvents and paint removers. Phosgene is a chemical intermediate for many other chemicals, dyes, polyurethane and some pesticides.