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  Introduction
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  By the NYC Health Commissioner
     
  9/11-Affected People
  Researchers
     



 
9/11 Health - Rescue and Recovery Workers

What We Know From the Research

FDNY and EMS Workers

Short-term Impacts (1-4 Years after 9/11)

FDNY first responders showed health effects soon after the attacks; 99% of exposed firefighters within the first week reported at least one new respiratory symptom while working at the World Trade Center site that they had not experienced before.1

Within the first six months after 9/11, “World Trade Center cough” was diagnosed in 3% of firefighters performing WTC rescue and recovery work who were enrolled in FDNY's WTC monitoring program and in 8% of those present during the collapse of the towers.2

Pulmonary function for firefighters in the year after 9/11 declined at a rate twelve times greater than the average decline expected with aging; for those exposed at the time of the tower collapse(s), the effects of the pulmonary decline were even greater.3

Before 9/11, one study showed a slightly higher than expected number of sarcoid cases among NYC firefighters, suggesting that firefighting posed some increased risk for the disease. 40 After 9/11, another study documented 13 cases of new-onset sarcoidosis or sarcoid-like diseases among NYC firefighters, an increase roughly 6 times higher than pre-9/11 levels. The rate subsequently decline to near-baseline levels, with 13 additional cases identified over the next 4 years.41

Among 10,378 firefighters who enrolled in the FDNY WTC Medical Monitoring and Treatment Program after 9/11 and were evaluated at yearly intervals over the first four years, cough and sore throat declined significantly from 54% to 16% and 62% to 36%, respectively. In contrast, the prevalence of other respiratory symptoms (dyspnea, wheeze, nasal congestion or GERD) remained relatively stable, between 45% to 35% over this time period. Initial arrival time at WTC site was linked with higher risk of respiratory symptoms at every exam, and in those evaluated at both year one and year four after 9/11, symptoms were linked to both earlier arrival time and longer work duration at WTC – each additional month of work increased the likelihood of symptoms by 8% to 11%.4

Among 8,487 firefighters who enrolled in the FDNY WTC Medical Monitoring and Treatment Program, 12% screened positive for probable PTSD symptoms in the first six months after 9/11. More than one-quarter (28%) of those who screened positive self-referred for counseling over the first 2.5 years after 9/11, a fivefold increase in the number of persons referred from pre-WTC rates. Elevated PTSD risk was significantly associated with counseling use, functional job impairment and mental-health related medical leave during this period.5

Mid-term Impacts (4-9 Years after 9/11)

FDNY researchers demonstrated that eight years after 9/11, the prevalence of several physician-diagnosed respiratory conditions among 10,999 WTC exposed male firefighters remained high in comparison to men in the general population. Firefighters 44 or younger were much more likely to report sinusitis/rhinitis (17.2% vs. 8.4%); bronchitis (13.2% vs. 3.3%) and COPD/emphysema (1.5% vs. 0.3%). Firefighters ages 45-65 were much more likely to report sinusitis/rhinitis (19.5% vs. 12.2%); current asthma (14.5% vs. 4.9%); bronchitis (13.2% vs. 3.2%); and COPD/emphysema (7.6% vs. 3.2%).30

The prevalence of probable PTSD among more than 11,000 firefighters in the FDNY WTC Medical Monitoring and Treatment Program nine years after 9/11 was four times higher than in the general population, 7.4% compared to 1.8%. Early arrival at the WTC site, exercising less and drinking more alcohol were associated with the persistence or onset of PTSD symptoms, as were co-occurring respiratory or gastroesophageal reflux symptoms.31

Steep and often disabling declines in pulmonary function first detected among firefighters and EMS workers within a year of 9/11 have persisted:  among those who never smoked, 13% of firefighters and 22% of EMS workers had below normal lung function for their ages 6 years later.19

Chronic airways disease was the main lung injury among firefighters with respiratory symptoms referred for evaluation within seven years after 9/11; few had interstitial fibrosis. Both conditions can range from mild to severe, although those with airways disease tend to respond better to treatment.20

Based on surveys of 12,000 firefighters and EMS workers between 2005 and 2008, the FDNY found that more than 36% were at high risk for obstructive sleep apnea (OSA). The earlier the arrival at the WTC site, as well as acid reflux, upper respiratory and PTSD symptoms were linked to increased risk for new-onset OSA among these workers.21

Substantial co-morbidity across physical and mental health conditions exists among firefighters. In a study of nearly 11,000 firefighters seven to nine years after 9/11, FDNY researchers found that 41.8% of those reporting symptoms of probable PTSD also self-reported a physician diagnosis of obstructive airways disease (OAD), which includes asthma, bronchitis or COPD/emphysema; 33.3% with probable PTSD or depression also self-reported a physician diagnosis of OAD. Among those with depression alone, 28.5% self-reported OAD. The researchers found similar results when they used medical records instead of self-reports for the analysis.32

FDNY researchers confirmed 263 new cases of cancer from September 11, 2001 through 2008 among 8,927 male firefighters who responded to the WTC disaster, 25 more than would have been expected among men of similar age, race and ethnicity in the general population according to the National Cancer Institute Surveillance Epidemiology and End Results (SEER) reference population. When researchers compared the WTC-exposed firefighters to unexposed firefighters they found a 19% increase in cancer overall, after making an effort to correct for both potential surveillance bias (due to changes in medical screening tests given after 9/11) and lead time bias (it is unlikely that any cancer would develop within two years of 9/11). Lack of statistical power prevented the researchers from drawing any conclusions about specific types of cancer.33

An analysis of retirement pensions awarded by FDNY found that in the seven years prior to 9/11, 48% of these pensions were for accidental disability. In the seven years after 9/11, accidental disability pensions comprised 66% of the total, with 47% (1,402 pensions) related to the WTC attacks and mostly due to respiratory illness. The FDNY study also estimated that WTC-related FDNY pensions added $826 million in increased costs to the system.34

Police Responders

Among 2,000 NYPD officers tested for coronary artery disease (including 75 who were early WTC responders), most of whom were under 60 years of age, the prevalence of premature heart disease was similar to the rate in the general population. 23

A longitudinal study of nearly 3,000 police responders enrolled in the WTC Health Registry found that prevalence of probable posttraumatic stress disorder doubled from 7.8% in 2003/2004 to 16.5% in 2006/2007. Female police were significantly more likely than male police to report PTSD symptoms in the first survey, but this gender difference disappeared by the second survey. PTSD risk factors included post-9/11 unemployment and disability. 29

Researchers at the New York/New Jersey WTC Clinical Consortium assessed nearly 8,500 police responders who sought services from 2002 through 2008 and found that the prevalence of posttraumatic stress disorder (PTSD) during the previous 30 days was comparable to that found in other studies of police responders. They also found a much higher rate of “subsyndromal” PTSD—not enough symptoms to meet the criteria for full PTSD—but which nevertheless was associated with a 5 times greater expressed need for mental health services, including 1-to-1 counseling, stress management or psychotropic medication, compared to those who didn’t meet the criteria for full or subsyndromal PTSD. 50

A longitudinal study of nearly 11,000 responders enrolled in the WTC Health Program (formerly called the New York/New Jersey WTC Clinical Consortium) looked at their mental health 3, 6 and 8 years after 9/11. The prevalence of posttraumatic stress disorder symptoms was much lower among police responders (22%) than construction workers (42%) in 2009, although the risk factors were the same for both groups: prior psychiatric history, Hispanic ethnicity, and severity of WTC exposure and WTC-related medical conditions. 52

Other Rescue and Recovery Workers

Short-term Impacts (1-4 Years after 9/11)

A study of more than 1400 New York State employees, including workers from the State Police, National Guard, and Department of Transportation, found that although they arrived later and had less intense exposure to conditions at the WTC site, state employees report increased rates of mental and physical health effects. Common mental health symptoms include sleep disturbance, excessive fatigue and irritability. Common physical ailments include respiratory symptoms such as dry cough.  State employees that were caught in the dust cloud were more likely to report both mental and physical health issues.6

Construction workers who participated in the clean-up effort, including truck drivers, heavy equipment operators, laborers and sanitation workers, were three times more likely to experience respiratory illness than those who did not work at one of the WTC sites. Start date, worksite location and duration of participation in the clean-up effort may also be associated with greater risk of respiratory symptoms.7

Among a sample of 9,442 rescue and recovery workers examined between July 2002 and April 2004 in what is now known as the WTC Responder Clinical Consortium, 32% self-reported lower respiratory symptoms and 44% reported upper-respiratory symptoms near the time of their medical evaluation.8

A study of rescue and recovery workers in the WTC Responder Clinical Consortium showed a strong association between worsened respiratory symptoms and early arrival at the WTC site.8

An analysis of blood samples from nearly 500 New York State employees and members of the National Guard who worked at the WTC site sometime between the attacks and December 2001 found concentrations of perfluorochemicals—manufactured chemicals used to make products that resist heat, oil, stains, grease and water—that were twice as high as those found in the general population. Levels of chemicals in the blood were similar between those who did and did not report symptoms, but were higher among those reporting higher levels of dust or smoke exposure. The blood samples were taken from May 2002 through November 2003 and the potential health effects of these chemicals are unknown. 13

A study of 136 rescue and recovery workers diagnosed with WTC-related atopy or allergies between 2003 and 2005 showed that those with atopy may have been at higher risk for upper airway disease, such as sinus or nasal congestion, than those not diagnosed with atopy. The study also found that workers with atopy had more serious airway disease symptoms. The prevalence of atopy (54%) was similar to that of the general population. 27

In studies of the mental health impacts on police officers and firefighters who participated in the WTC response, more than two-thirds reported experiencing at least one disaster-related stress symptom 15 to 27 months after the attacks. 14

Two studies of more than 3,000 mostly male utility workers who were screened for mental health conditions at their place of employment offer insights about early traumatic stress among WTC recovery workers:

  • Ten to 22 months after 9/11, eight percent of 2,960 workers had symptoms consistent with full PTSD, 6% with depression, 3.5% with anxiety and 2.5% with panic disorder. Believing that their life had been in danger was the best predictor of PTSD among these workers. 38
  • Workers with trauma symptoms who didn’t meet the criteria for full or sub-threshold PTSD within the first two years of 9/11 were screened again one and two years later. 29% met the criteria for sub-threshold or full PTSD at Time 2 and 24.5% met these criteria at Time 3. In addition, workers with sub-threshold PTSD reported levels of impairment roughly four times greater than workers with no PTSD symptoms. 39

The prevalence of probable post-traumatic stress disorder (PTSD) among rescue and recovery workers enrolled in the WTC Health Registry increased from 12.1% 2-3 years after the attacks to 19.5% 5-6 years after the attacks. Probable PTSD was late onset for many of these workers, meaning that their symptoms worsened between the two time periods. Risk factors for developing probable PTSD among rescue and recovery workers included arrival at the site on 9/11 or working longer than 90 days. 9

Mid-term Impacts (4-9 Years after 9/11)

Injury as a result of the 2001 terrorist attack on the World Trade Center, including, for instance, broken bones or burns, increased the risk of chronic disease 5-6 years after 9/11, according to a study of more than 14,000 enrollees who reported no previous diagnosis of heart disease, respiratory disease, diabetes or cancer. Enrollees who reported more than one injury—a group of nearly 2,000 people—were twice as likely to also report respiratory illness as those who were not injured. Enrollees with multiple injuries and probable posttraumatic stress disorder (PTSD) were three times more likely to report heart disease than those with no injuries and no PTSD. 54

An analysis of verified cancer diagnoses among 21,850 rescue and recovery workers enrolled in the WTC Health Registry found small increases in rates of three types of cancer—prostate cancer, thyroid cancer and multiple myeloma—in 2007-2008 compared to non-exposed New York State residents during the same period. 51

An analysis of confirmed cancer cases diagnosed since 9/11 among 20,984 rescue and recovery workers enrolled in the federal WTC Health Program (formerly known as the WTC Responder Clinical Consortium) found 15% more cancer cases than expected overall; however, when the analysis was restricted to cancer cases diagnosed after 6 months of enrolling in the program (which opened in July 2002), only 6% more cancer cases were found. Both analyses found more thyroid and prostate cancer cases than expected.53

More than 12 percent per cent of the 25,000 rescue and recovery workers enrolled in the WTC Health Registry report developing new-onset asthma sometime during the 5-6 years since working at the WTC site, a rate  higher than what normally would be expected for the adult population during such a time period. Rates of new asthma were highest among workers who arrived at the pile on September 11, 2001 (20.5%) or worked more than 90 days at any WTC site (17.3%). 9

A prospective study of nearly 21,000 rescue and recovery workers who sought care at the WTC Responder Clinical Consortium compared self-reports of asthma in this group to an annual health survey of the general population. While the prevalence of ever having asthma remained steady at about 10% from 2000 to 2007 in the general population, it increased from 3% before 9/11 in WTC responders to 19% in 2007. WTC responders were also more than twice as likely to report asthma during the past 12 months as people in the general population. 47

A clinical study of more than 3,000 workers examined twice at least 18 months apart between 2002 and 2007 at the WTC Responder Clinical Consortium found that weight gain between exams but not degree of WTC exposure was associated with continued loss of pulmonary function. An additional risk factor for continued loss of pulmonary function was abnormal bronchodilator response, which can be indicative of asthma, on the first exam. The majority continued to have pulmonary function within the normal range but the prevalence of reduced pulmonary function at the time of the second exam remained higher than in the general population.10

Clinical studies of WTC rescue, recovery and clean-up workers who had voluntarily enrolled in a monitoring program at the WTC Responder Clinical Consortium indicate that respiratory problems have persisted for some, and that respiratory problems often co-occur with other diagnoses:

  • A small study of 42 sequentially-selected patients with gastroesophageal reflux disease (GERD) suggests that it may be related to abnormal lung function.11
  • Among 172 randomly selected workers, ten were diagnosed with vocal cord dysfunction (VCD), which can cause hoarseness or pain while breathing. The workers also all had GERD and chronic rhinitis. Although the study was not designed to determine whether VCD was directly associated with WTC exposure or indirectly associated with other conditions such as PTSD or GERD that have been linked more directly with WTC exposure. These preliminary findings suggest that VCD may be part of a spectrum of WTC-related respiratory disorders.12

The New York State Department of Health found that responders with moderate exposure were more likely to report persistent lower respiratory symptoms (including cough, wheeze, shortness of breath and chest tightness) but not asthma five years after 9/11 compared to a control group. Those with prior asthma and those most exposed to the dust and smoke were more likely to report more serious asthma symptoms.22

Researchers at the WTC Responder Clinical Consortium found an increased incidence of sarcoidosis among nearly 20,000 rescue and recovery workers who sought care for 9/11-related health problems in comparison with other published background rates, although no association was found with date of arrival at the WTC site, or exposure to the dust cloud released by the collapse of the buildings. Thirty eight new cases were verified from 2002 to 2007, with the highest incidence occurring 2 and 3 years after 9/11.42

Using biopsy results, WTC Health Registry researchers confirmed 43 cases of sarcoidosis among adults in its cohort of rescue and recovery workers, Lower Manhattan residents, area workers and passersby. A nested case control study found that working on the WTC debris pile significantly increased the sarcoidosis risk for rescue and recovery workers; no risk factors were identified for other groups.43

A study of rescue and recovery workers who snored and were diagnosed and treated for respiratory disease, acid reflux symptoms or a mental health condition between 2003 to 2006 found that 62% had obstructive sleep apnea. There were no associations found with these conditions or WTC occupational exposures.24

Researchers investigating obstructive sleep apnea (OSA) at the WTC Responder Clinical Consortium compared a group of 50 rescue and recovery workers with aerodigestive symptoms who reported habitual snoring 6 to 7 years after 9/11 to a similar group of men without WTC exposure who also snored habitually. OSA was associated with body mass index and weight in the group without WTC exposure but not in the WTC workers, suggesting that factors other than obesity may contribute to OSA among WTC responders with aerodigestive disorders.44

Two small studies of rescue and recovery workers who received care at the WTC Responder Clinical Consortium found that:

  • Rescue and recovery workers, especially those exposed to the dust cloud on 9/11, were less likely to detect nasal irritation or odors more than two years later.25

     

  • Rescue and recovery workers were less likely to detect odors seven years later. This was not related to the severity of upper respiratory illnesses among the group.26

A New York State Department of Health study of 43 WTC responders found that their blood contained higher rates of chemicals that are normally released when solid municipal waste is burned than the general population.28

A longitudinal study of more than 27,000 rescue and recovery workers who sought treatment at the WTC Responder Clinical Consortium conducted detailed physical examinations on each worker and also assessed workers’ self-reports of physician diagnoses from 2002 to 2010. Nine years after the terrorist attacks, among those still in treatment, 18.1% (1,893) still had active asthma; 20% (2,042) had sinusitis, and 32.6% (3,195) had gastroesophagael reflux disorder (GERD). All three conditions were associated with higher levels of WTC exposure among workers.35

Spirometry, an objective test to measure how well the lungs’ large airways are functioning, validated subjective respiratory symptoms in a group of nearly 19,000 rescue and recovery workers being monitored at the WTC Responder Clinical Consortium. Workers reporting persistent cough, wheezing, or difficulty breathing upon exertion were more likely than workers without symptoms to have lower lung function and a higher rate of bronchodilator responsiveness during their first clinical visits between 2002 and 2008.36

The nine-year cumulative incidence for spirometric abnormalities among 5,769 responders at risk in the WTC Responder Clinical Consortium was 41.8%; three-quarters of these abnormalities were low forced vital capacity, a measurement taken when the responders were asked to exhale all the air in their lungs as forcefully as possible.34

In a longitudinal study of 139 NYPD emergency service workers who responded to the WTC disaster, NYPD researchers found evidence of mild declines in lung function six years later, in comparison to pre-9/11 baseline data. Abnormal spirometry, seen in 5.3% of the cohort, was associated with earlier arrival and longer duration at the WTC site. The greatest declines were seen in smokers and workers without respiratory protection.37

A study of more than 10,000 rescue and recovery workers monitored at the WTC Responder Clinical Consortium over a five-year period from 2002 to 2007 indicated that 17% may have alcohol problems; 11% met the criteria for probable PTSD; 9% had probable depression; and 5% had probable panic disorder.  PTSD, which affects 3-4% of the U.S. adult population, was significantly associated with loss of family members and friends, disruption of family, work and social life, and higher rates of behavioral symptoms in their families.15

Studies of WTC rescue and recovery workers have found that trauma either before or after the 9/11 terrorist attacks increased their vulnerability to PTSD or resulted in greater symptom severity:

  • Among 842 utility workers who were deployed to the WTC site and who participated in a voluntary psychological screening 17 to 27 months later, those with PTSD were more likely to have a history of trauma, depression and panic disorder prior to 9/11. In addition, the study found that the ability to function at work, or in family and social situations decreased with PTSD symptom severity.16
  • A clinical study of 124 ironworkers who worked at the WTC site and who sought mental health treatment 14 to 17 months after 9/11 at the WTC Responder Clinical Consortium found significantly elevated rates of alcohol misuse (39%); anxiety (6.5%); and PTSD (18.5%), in comparison to the general population. Psychiatric symptoms were correlated with excessive alcohol use since 9/11, injury to and/or death of a friend, family member or co-worker on 9/11, and at least one adverse life event in the six months after 9/11.17

A study of more than 1,000 WTC rescue and recovery workers suggests that disaster workers with high levels of anger may benefit from early intervention to prevent chronic posttraumatic stress disorder (PTSD). Those with low levels of anger experienced fewer PTSD symptoms over a one-year period than those with high levels of anger. Workers with higher levels of anger also had more severe symptoms of depression and other psychiatric problems.18

Clinician-measured rates of PTSD among a group of 727 utility workers deployed to the WTC site declined from 14.9% in 2002-2004 to 5.8% in 2007-2008. The strongest predictors of ongoing PTSD 6 years after 9/11 were trauma history, major depression following the trauma, and extent of occupational exposure. 48

Nine years after 9/11, WTC rescue and recovery workers in the WTC Responder Clinical Consortium, excluding police responders, continued to screen positive at high rates for PTSD (19.2%), depression (17.9%) and panic disorder (12.3%). Police responders had much lower rates of these conditions: PTSD (5%), depression (4.5%) and panic disorder (4.8%).35

Rescue and recovery workers who sought treatment at the WTC Responder Clinical Consortium from 2002 – 2010 also reported substantial co-morbidity: in a clinical population of more than 27,000 workers, nearly half with asthma (1,459 workers) also reported at least one mental health condition, as did more than a third of workers with either sinusitis (2,006 workers) or GERS (2,348 workers). Similarly, around 70% of workers who reported PTSD (2,806 workers), depression (2,153 workers), or panic disorder (1,129 workers) also reported a physician diagnosis of at least one physical disorder.35

A study based on the initial screening data of nearly 21,000 rescue and recovery workers in the WTC Responder Clinical Consortium from 2002 to 2008 suggests that PTSD may be contributing to the persistence of respiratory symptoms. 49

Eight years after 9/11 a study of more 6800 non-traditional responders including construction, installation, repair and transportation workers, and security guards enrolled in the WTC Health Program (formerly called the WTC Responder Clinical Consortium) found that nearly 10% had symptoms of severe posttraumatic stress. Risk factors included prior psychiatric history, Hispanic ethnicity, and severity of WTC exposure and WTC-related medical conditions.52

 

 

Volunteers

A longitudinal study of 4,974 adult volunteers enrolled in the WTC Health Registry draws distinctions between affiliated volunteers and lay volunteers. Compared to affiliated volunteers, lay volunteers were:

  • more likely to have been present in lower Manhattan, experienced the dust cloud, witnessed horrific events, had an injury on 9/11 and reported unmet health care needs.
  • nearly twice as likely to have reported an early post-9/11 mental health diagnosis or a diagnosis of asthma or reactive airways dysfunction syndrome.
  • more than twice as likely to have had chronic PTSD, late-onset PTSD, or new or worsening lower respiratory symptoms.45

 

 

Respiratory Protection

A longitudinal study of 9,296 rescue and recovery workers enrolled in the WTC Health Registry who worked at least one shift on the WTC debris pile offers new insights into the use of respiratory protective equipment (RPE):

  • Fewer than 20% of workers reported use of standard respirator models on 9/11 and half of the workers wore no facial covering of any kind on that date.
  • The strongest predictors of using adequate RPE were affiliation with construction, utilities or environmental remediation organizations, and prior training in the use of RPE.
  • Workers who reported no respiratory protection were more likely to report recurrent respiratory symptoms and some respiratory disease compared to those who used respirators.46

 

 

References

  1. Progress Since 9/11: Protecting Public Health and Safety Against Terrorist Attacks. PDF Document (Reader Required; Click to Download) Hearing Before the Subcommittee on National Security, Emerging Threats and International Relations of the House Committee on Government Reform. Feb. 28, 2006; testimony of Kerry J. Kelly, MD, Chief Medical Officer, Bureau of Health Services, Fire Department of New York and Co-Director, Fire Department of New York-World Trade Center Medical Program New York City.
  2. Prezant DJ, Weiden M, Benauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. New England Journal of Medicine. 2002. 347; 806-815.
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