FDNY and EMS Workers

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

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

Other Rescue and Recovery Workers

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 Medical Monitoring and Treatment Program, 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 Medical Monitoring Program showed a strong association between worsened respiratory symptoms and early arrival at the WTC site.⁸

More than 12 percent per cent of the 25,000 rescue and recovery workers enrolled in the World Trade Center 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 clinical study of more than 3,000 workers examined twice at least 18 months apart between 2002 and 2007 at the New York/New Jersey WTC 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 New York/New Jersey 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

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

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

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

A study of more than 10,000 rescue and recovery workers monitored at the Mount Sinai WTC 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 New York/New Jersey WTC Treatment 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

References

1. Progress Since 9/11: Protecting Public Health and Safety Against Terrorist Attacks.   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.
3. Feldman DM, Baron SL, Bernard BP et al. Symptoms, Respiratory Use and Pulmonary Function Changes among New York City Firefighters Responding to the World Trade Center Disaster. Chest. 2004; 125(4):1256-1264.
4. Webber MP, Gustave J, Lee R, et al. Trends in Respiratory Symptoms of Firefighters Exposed to the WTC Disaster: 2001-2005. Environmental Health Perspectives 2009; 117(6):975-980.
5. Corrigan M, McWilliams R, Kelly K, et al. A Computerized Self-administered Questionnaire to Evaluate Posttraumatic Stress in Firefighters after the WTC Collapse. American Journal of Public Health 2009; In Press.
6. Mauer MP, Cummings KR, Carlson GA. Health effects in New York state personnel who responded to the world trade center disaster. Journal of Occupational and Environmental Medicine. 2007. 49;1197-1205.
7. Tao X, Massa J, Ashwell L et. al: The World Trade Center Clean Up and Recovery Worker Cohort Study: Respiratory Health amongst Cleanup Workers Approximately 20 Months after Initial Exposure at the Disaster Site. Journal of Occupational and Environmental Medicine. 2007. 49;1063-1072.
8. Herbert R, Moline J, Skloot G, et al.  The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program .  Environmental Health Perspectives. 2007. 115; A71-2.
9. Brackbill RM, Hadler JL, Ekenga CC, et al. Asthma and Posttraumatic Stress Symptoms 5 to 6 Years Following Exposure to the WTC Terrorist Attack. Journal of the American Medical Association 2009; 302(5):502-516.
10. Skloot GS, Schechter CB, Herbert R, et al. Longitudinal Assessment of Spirometry in the WTC Medical Monitoring Program. Chest 2009; 135(2): 492-498.
11. de la Hoz RE, Christie J, Teamer J, et al. Reflux Symptoms and Disorders and Pulmonary Disease in Former WTC Rescue and Recovery Workers and Volunteers. Journal of Occupational and Environmental Medicine 2009; 50(12): 1351-1354.
12. de la Hoz RE, Shohet MR, Bienenfeld LA, et al. Vocal Cord Dysfunction in Former WTC Rescue and Recovery Workers and Volunteers. American Journal of Industrial Medicine 2008; 51(3): 161-165.
13. Tao L, Kannan K, Aldous KM, et al. Biomonitoring of Perfluorochemicals in Plasma of New York State Personnel Responding to the WTC Disaster.. JEnvironmental Science & Technology 2008; 42(9): 3472-3478
14. Dowling FG, Moynihan G, Genet B, et al:  A peer-based assistance program for officers with the New York City Police Department: report of the effects of Sept. 11, 2001. American Journal of Psychiatry.  2006. 163; 151-3.
15. Stellman JM, Smith RP, Katz CL, et al. Enduring Mental Health Morbidity and Social Function Impairment in WTC Rescue, Recovery, and Cleanup Workers: The Psychological Dimension of an Environmental Health Disaster. Environmental Health Perspectives 2009; 116(9): 1248-1253.
16. Evans S, Patt I, Giosan C, et al. Disability and Posttraumatic Stress Disorder in Disaster Relief Workers Responding to September 11, 2001 WTC Disaster. Journal of Clinical Psychology 2009; 65(7): 684-694.
17. Katz CL, Levin S, Herbert R, et al. Psychiatric Symptoms in Ground Zero Ironworkers in the Aftermath of 9/11: Prevalence and Predictors. Psychiatric Bulletin 2009; 33: 49-52.
18. Jayasinghe N, Giosan C, Difede J, et al. Anger and Posttraumatic Stress Disorder in Disaster Relief Workers Exposed to the September 11, 2001 World Trade Center Disaster: One-Year Follow-Up Study. Journal of Nervous and Mental Disease. 2008. 196(11); 844-6.