Investigation of an outbreak of anemia cases at an Army trinitrotoluene munitions production plant from 2004 to 2005 and subsequent surveillance 2005-2013.
OBJECTIVE
Investigate an outbreak of anemia that occurred at an Army trinitrotoluene (TNT) munitions production facility in 2004-2005 and describe subsequent medical surveillance efforts between 2005 and 2013.


METHODS
A retrospective, cross-sectional investigation of anemia cases and exposure levels was conducted to target corrective engineering and administrative changes needed to reduce TNT levels and anemia cases.


RESULTS
Mean TNT exposure levels decreased from 1.2 to 0.08 mg/m(3) between 2004 and 2012, but the trend was not statistically significant. Anemia cases rose from 17 to 38 between 2004 and 2011 and cases declined from 4 to 0 between 2012 and 2013. The overall trend in cases was not statistically significant.


CONCLUSIONS
TNT levels rose at a munitions plant until ventilation changes reduced exposures. Despite this, anemia cases continued to rise until the commander held workers accountable for failing to wear PPE and motivated them to wear respirators to avoid a loss in pay. The case definition of anemia was revised to be consistent with the case definition used by private physicians who practiced in the community. Better coveralls are needed, which are easy to wear, reduce static discharge, and prevent TNT skin absorption.
Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 21044.
Timothy M
TM
Mallon
G3/5/7Health & Wellness Directorate (3SW318D), Office of the Surgeon General 7700 Arlington Boulevard, Falls Church, VA 22042.
Jose M
JM
Ortiz
Springfield Clinic MOHA, 775 Engineering Drive, Springfield, IL 62703.
William H
WH
Candler
Building 5, 1 C-Tree Road, Occupational Health Clinic, McAlester Army Ammunition Plant, McAlester, OK 74501.
Gregory
G
Rogers
Building 5, 1 C-Tree Road, Occupational Health Clinic, McAlester Army Ammunition Plant, McAlester, OK 74501.
Richard
R
Hillburn
D000328:Adult; D000368:Aged; D000395:Air Pollutants, Occupational / Q000009:adverse effects; D000743:Anemia, Hemolytic / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D053834:Explosive Agents / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D066192:Manufacturing Industry; D008875:Middle Aged; D008889:Military Personnel / Q000706:statistics & numerical data*; D009784:Occupational Diseases / Q000453:epidemiology*; D016273:Occupational Exposure; D011159:Population Surveillance; D012134:Respiratory Protective Devices; D012189:Retrospective Studies; D014303:Trinitrotoluene / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology; D014691:Ventilation / Q000379:methods; D054041:Weapons; D055815:Young Adult
D000395:Air Pollutants, Occupational; D053834:Explosive Agents; D014303:Trinitrotoluene