Listing of Registry Research Publications by Year
This paper compared the children in the Registry to all children in Lower Manhattan on September 11, 2001. We found that the Registry children are similar by age and sex to all children. Black and Hispanic children are slightly over-represented and Asian children are under-represented. This study shows it would be unnecessary to create a new Registry of 9/11 children more than 20 years after September 11, 2001.
One of the most common 9/11-health-related conditions is post-traumatic stress disorder (PTSD). People with PTSD have disturbing memories of 9/11. PTSD can cause people to have difficulty working, home life, and socializing. This study found that those with more social support and did physical exercise with multiple PTSD symptoms had no impairment. Those with low PTSD symptoms who reported poor health had low social support and no exercise to have difficulty working, home life, and socializing.
Opioid pain medication is often used to treat Rheumatoid Arthritis (RA). This is a new health issue for people exposed to the 9/11 disaster. This study found that people with RA use more opioids than people without RA. It also found that for someone who has RA, PTSD has no effect on taking more opioids or not. It is essential to evaluate the risk and use of opioid medication to lower the chance of overuse by RA patients exposed to the 9/11 disaster.
A recent Registry study looked at the role of Post-Traumatic growth in Health and Quality of life. Results showed that those who were physically injured during 9/11 experienced better mental functioning than those who did not.
Enrollees exposed to 9/11 continued to have poor control of their asthma despite treatment. This study looked at the relationships among asthma, mental health, and quality of life. Results suggest that a study of simultaneous treatment of asthma and mental illness are needed to improve this situation.
This study looked at the increase in deaths and COVID-19 related deaths among the New York City residents exposed to the 9/11 disaster. We found that death increased 3-fold in this 9/11-exposed population during year 2020. We also found non-Hispanic Black and having at least one chronic condition increased the chance of dying from COVID-19 infection. This study highlights the importance of reducing transmission risk in communities of color.
This study found that the risk of dying of a post-9/11 cancer was increased when the enrollee also had PTSD. In rescue/recovery workers, the overall risk of dying from a non-cancer related disease was increased if they had PTSD. The risk was also increased if they witnessed three or more traumatic events on 9/11. We did not see a link between 9/11-related exposure and cancer deaths among WTCHR enrollees.
This paper reports on WTC survivors with Post Traumatic Stress Disorder and the relationship between self-efficacy and those seeking mental health help. Studies show that those with high-self efficacy are less likely to have PTSD then those with low self-efficacy. Those with lower self-efficacy were more likely to seek mental health treatment.
Individuals present in lower Manhattan during the 9/11 World Trade Center (WTC) disaster likely suffered from psychological distress. People have different experiences of distress over time. This study showed five different ways of having psychological distress over time. These include no distress, low distress that did not change, distress that increased over time, distress that decreased over time, and always high level of distress. 78% were in the no distress group. Women, young at the time of 9/11, lower education had more distress than no distress group. Non-rescue/recovery workers with a lot of traumatic exposure were also more likely to be more distressed over time.
This study looked at whether the WTC disaster affected on math and English language arts (ELA) test scores among New York City (NYC) public school students. Test scores over five years from 1998 to 2003 from the NYC Department of Education were used in this study. Among students exposed to the WTC attacks, there were no changes in test scores after 9/11 exposure. Students in unexposed schools increased the scores on ELA exams after 9/11, but with small decreases in math test scores after 9/11. Futures studies should at changes in education outcome over longer periods of time.
The study looked at a group of people who had a direct experience with both 9/11 and Hurricane Sandy. Those who felt they were not prepared for the storm or had a financial loss reported higher levels of stress. Those who had a feeling gratefulness or patriotism in relation to their experience reported lower levels of stress.
This review looks at the study results that have been conducted among WTC-RRWs over the last twenty years after 9/11. And the link between exposure at the World Trade Center site and the evidence of an increased risk for certain types of cancers.
This paper reviewed recent studies of cancer risk among WTC responders and rescue and recovery (RRW) workers. It focused on studies based on combining information from three WTC-exposed responder cohorts. RRW were exposed to WTC dust and debris that contained many known and suspected cancer-causing elements. The review showed that WTC exposure was related to an increased risk of skin melanoma and tonsil cancer among RRW. It also noted better cancer survival among those enrolled in a WTC- medical monitoring and treatment program (WTC-MMTP) compared to those not enrolled. Cancer survival among those enrolled in a WTC-MMTP was also better than that of the New York State general population. Routine check-ups of RRW in a MMTP also led to an increase in detection of thyroid cancer.
This paper reports on thyroid cancer in WTC rescue and recovery workers (RRW). It looked at RRW from three WTC-exposed cohorts through 2015. Incidence of thyroid cancer in those enrolled in a WTC-medical monitoring and treatment program (WTC-MMTP) was more than double that of the New York State population. There was no difference in thyroid cancer incidence between those not enrolled in a WTC-MMTP and the NYS population.
Being in a WTC-MMTP that includes screening may increase the identification of thyroid cancer.
This study looked at whether PTSD symptoms would lead to having less social support. Those with 9/11-related PTSD symptoms were more likely to report less social support, and vice versa. Our findings show the importance of having a strong social support network to help protect mental health after a disaster, and over time.
This study found that 9/11-related posttraumatic stress disorder (PTSD) was associated with systemic autoimmune disease (SAD) in community members. A high level of dust exposure was associated with an increased risk of SAD among 9/11 responders. The relationship between 9/11 exposures, SAD, and PTSD will need further study based on larger numbers of cases of SAD.
Many studies were on why adults were in hospital after 9/11, but few were on children. Young enrollees were linked to NYS data to identify hospitalizations. We studied what link to their hospitalization. 3151 of them were less than 18 years old on 9/11 in the Registry, 7.7% of them had one 9/11 related physical health hospitalization or more. 8.9% of them had one 9/11 related mental health hospitalization or more. Non-White race, living in public housing, 9/11 dust cloud exposure, and PTSD were linked to be hospitalized for a 9/11-related physical condition. Older age and PTSD were linked hospitalized for a 9/11-related mental condition. It’s important to know the factors that have long-term 9/11 effects on the minors.
Post-traumatic stress disorder affects weight. This study showed that people exposed to WTC disaster and who had PTSD gained weight over time. Obesity was most common among the people with chronic PTSD (39.5%) and not every time PTSD (36.6%), compared to those with no PTSD (29.3%). Also people with a history of PTSD after 9/11 were more likely to have obesity and weigh more over time. These findings confirm the need for a focus on both physical and mental health to improve health outcomes.
Cone JE, Albeliz S-C, Lucchini R. “9/11 Health Update.” International Journal of Environmental Research and Public Health. June 2021, 18, 6383. /doi.org/10.3390/ijerph18126383
This paper reports on cancer survival among WTC rescue and recovery workers. We studied workers from three WTC-exposed responder groups. Those diagnosed with cancer between 2005 and 2015 were included. We found that workers enrolled in a World Trade Center medical monitoring and treatment program (WTC-MMTP) had a 28% lower cancer death rate. They also had a 36% lower all-cause death rate, compared to NYS general population. There was no difference in survival between those not enrolled in a WTC-MMTP and the NYS general population.
Enrollment in a WTC-MMTP that includes screening and no out-of-pocket‐cost treatment may help improve survival among WTC cancer patients.
The article shows the ways those exposed to 9/11 might have cognitive impairment and that there are treatments. Physical activity and treatment of PTSD symptoms can help. The research will continue because 9/11 survivors may have a greater risk for this condition than others.
The study looked at frequent moving and the chance of depression with adults exposed to the 9/11 disaster. We also looked at how relationships were affected. We found that most enrollees did not move in 2007–2014. However, frequent moving was associated with a risk of depression compared to not moving. We also found that keeping social networks could help ease the chance of depression with the enrollees who moved most.
This study looked at the cases of cutaneous melanoma in WTC rescue and recovery workers (RRW) between 2002 and 2015. Overall, the risk of cutaneous melanoma was higher among RRW compared to the New York state population. Also, those who worked at the disaster site in the first week after 9/11, and those who worked on the debris pile, had an increased risk. This study included RRW from three 9/11 cohorts (WTC Health Registry, FDNY, and Mount Sinai). Findings show the need for ongoing cancer monitoring of workers.
This study looked at prostate cancer during 2002-2015 (check) in WTC-exposed rescue and recovery workers (RRW) compared to the New York State population. We found a 24% increase in cancer risk beginning at about 5 years after exposure. Those who arrived at the site during the first two days after 9/11 had higher risk than those who arrived later. This study included RRW from three 9/11 cohorts (WTC Health Registry, FDNY, and Mount Sinai). The findings help understand the time between environmental exposure and the risk of developing cancer.
The study looked at the relationship between social and emotional embeddedness and posttraumatic stress disorder (PTSD). Social embeddedness refers to a group of friends that can provide a feeling of belonging. Emotional embeddedness refers to being emotionally connected to people around you. We found that people with PTSD had the smallest friend group. Those who reported little to no PTSD reported the most friendships. It may be helpful for clinicians to address the social needs of those experiencing PTSD.
In this study, we looked at patterns of enrollee responses to the 2017–2018 Health & Employment Survey (HES). The overall completion rate was 65%. The likelihood of responding to HES was more than doubled when the web survey was an option compared to paper survey only (when enrollees did not have a valid email address on record). Most web surveys were received during the first two months of data collection compared with less than one-third of paper surveys. Multiple email reminders resulted in increased responses. To offer both mode options to all enrollees, more efforts should be made on collecting valid email addresses.
In this recent case study, we used medical examiner information to learn more about 9/11-related suicides among World Trade Center Health Registry enrollees. We identified 35 enrollee suicides that happened in New York City during 2004-2018. Most of the cases were non-Hispanic white (66%), male (83%), rescue/recovery workers (54%), and middle-aged (median 58 years).
Sixty percent of the cases had depression mentioned in the files, but none mentioned PTSD. Rescue/recovery workers may be at extra risk for suicide. Mental health screening and treatment must be prioritized for the 9/11-exposed population.
This study looked at people who reported having both Post-9/11 Asthma and COPD on the Registry’s 2015-16 survey. This study found that those exposed to the dust cloud, those reporting higher number of injuries, and WTC rescue/recovery workers had a greater chance of developing both Asthma and COPD. More research may help us better understand the link between a [person developing both Asthma and COPD after exposure a large respiratory irritant.
Many survivors of the 9/11 terrorist attacks in New York City were injured. This study looked to understand how 9/11-related injuries affected retirement plans of WTC Health Registry enrollees. Study results showed that injured enrollees were more likely of retiring at younger ages compared to non-injured enrollees. Enrollees who retired with less severe injuries, were much more likely to return to work. Our results suggested that being injured on 9/11 was associated with early retirement if the injuries had not occurred, the person may have continued working longer.
Previous studies reported that people with 9/11-related PTSD who experienced another stressful event were more likely to re-develop 9/11-related PTSD symptoms. Being told you have cancer can be a very stressful event and can bring back a person’s PTSD symptoms. We looked at the change of 9/11-related PTSD symptoms after a cancer diagnosis in people who were exposed to the WTC disaster. We found that 9/11-related PTSD symptoms in men were slightly increasing before the cancer diagnosis and reversed after the diagnosis. No trend was noticed in the women. The reduction in the men was seen mostly in the rescue/recovery workers with an advanced state of the disease. Further research is needed to explain the reasons behind this change.
This paper investigated the relationship between 9/11-related posttraumatic stress disorder (PTSD), dust exposure, and stroke. The study was conducted upon 29,012 people in the World Trade Center Health Registry. The stroke information was gathered from the New York State Department of Health’s discharge records.
We found that PTSD is a risk factor for stroke and is associated with recurrent strokes. We also found that dust exposure on 9/11 is a possible risk factor for a stroke caused from a blockage in an artery that supplies blood to the brain. Policy makers and medical professionals should place greater emphasis on treating PTSD among 9/11 survivors. This may ultimately reduce the risk for stroke and recurrent strokes.
This study looked at how long it took for a WTC rescue/recovery worker to develop prostate cancer after exposure to 9/11. We found a 24% increase in the risk of developing prostate cancer. That increase is compared with the New York State general population. Unique exposures at the disaster site might have contributed to the number of prostate cancer cases. Continued research to into 9/11 and prostate cancer in WTC responders is needed.
This paper is the result of working with three responder cohorts, including the Fire Department of the City of New York (FDNY), the World Trade Center Health Registry (WTCHR), and the General Responder Cohort (GRC) to report the associations between WTC-exposures and rare cancers.
Combining the three cohorts enabled researchers to collect data from a larger study group. Records from the FDNY, WTCHR, and GRC were combined resulting in 69,102 unique individuals. Overall, 7894 cancer tumors were matched to the study group, increasing the number of cancers by as much as 58% compared to previous studies. This combining of study group participants resulted in an effective resource for future research studies on rare cancers and mortality, with more representative of occupations and WTC- exposure.
This study looked at enrollees who lived in New York State during 2001-2016 and were World Trade Center responders and people who lived in the community. Those with more exposure to 9/11 were more likely to be hospitalized for a condition caused by drinking alcohol than other people with less 9/11 exposure. We also saw a link between having 9/11-related post-traumatic stress disorder symptoms and hospitalization due to excessive alcohol drinking. Our findings show effects on physical and mental health after a disaster and over time.
The adverse physical and mental health effects of the 9/11 World Trade Center attacks have been well documented. Posttraumatic growth (PTG) is also important and necessary to monitor since positive outcomes and attributes of well-being are an important part of one’s health. The presence of PTG was assessed among 4,934 people who completed the WTC Health Registry’s survey on Health and Quality of Life 15 years after 9/11. PTG refers to the positive psychological change following a traumatic event that results in improved -level of functioning. Unlike resilience, PTG allows individuals to surpass pre-trauma functioning and not simply return to their baseline level of functioning. Some (~34%) participants experienced moderate-to-high level of PTG. Having a very high level of 9/11-related exposure and greater levels of social integration, social support, and self-efficacy was associated with a slight increase in PTG. Trauma treatment for 9/11 victims should consider PTG and the extent it can aid patients facing adversity.
The study looked at the link between posttraumatic stress disorder (PTSD) and lower respiratory symptoms (LRS) among survivors of 9/11. The study used the results from a previous test of World Trade Center rescue/recovery workers and exposed community members. The results were that PTSD and LRS each mediated the other. A diagnosis of either should be a sign to see if the other condition exists.
This paper is about record linkage which is combining records from different sources. This is done to increase the amount of information available for studies. There are different types of record linkage. The main type uses the likelihood that the same persons is in each source. This is called probabilistic record linkage. Three types of probabilistic record linkage are described. Other problems such as making sure information is useful and that the information is protected are discussed. Using record linkage for studying long-term complications of disasters, such as 9/11 are also discussed.
This was a joint study with the NYU Grossman School of Medicine and Bellevue Hospital. The aim was to learn about lung function in healthy people in an urban setting. It used oscillometry testing data from the control group of an earlier study of lung function in people exposed to 9/11 dust. The study found that it helps to consider height and BMI when predicting lung function using respiratory oscillometry.
Previous work found that people who were affected by the 9/11 terrorist attacks in NYC tended to binge drink more. This study looked at drinking behavior among WTC Health Registry enrollees before and after Hurricane Sandy struck in October/Nov 2012.
Binge drinking was defined as drinking five or more alcohol drinks on one occasion for men and four or more drinks for women. We found that those without 9/11-related PTSD who had Sandy-related PTSD were more likely to start and continue binge drinking after Sandy. Those with 9/11-related PTSD did not change their binge drinking behavior after Sandy. Future disaster responses should plan for treatment of alcohol use and PTSD at the same time.
Moving can impact health. This can happen due to changes in environment, social networks, and other neighborhood factors. We looked at moving among WTC Health Registry enrollees from 2004 to 2016. Displacement was when people moved to a more disadvantaged neighborhood. We found that the number of moves was not associated with common chronic diseases in this mostly urban cohort. The risks of diabetes and hypertension was similar between those who moved three times or more and those who never moved. Displacement was not associated with diabetes nor hypertension.
As part of its work, the WTC Health Registry tracks deaths among enrollees. This study compared several methods for processing the results of Registry matches to the National Death Index (NDI) to confirm deaths among enrollees. These included methods from the National Institute of Occupational Safety and Health, the National Program of Cancer Registries (NPCR); and criteria set by NDI. We found that the method from the NPCR reduced the number of false-matches and made the manual review process easier. The Registry has now adopted the NPCR method for processing NDI matches.
Post-traumatic stress disorder (PTSD) was the most common mental health condition associated with the 9/11 terror attacks. This study found that the risk of self-medication with alcohol increased as the number of PTSD symptoms increased. Many of the people exposed to 9/11 continue to have PTSD symptoms and may use alcohol to feel better. Repeated check-ups for alcohol use among survivors of mass-traumas with PTSD symptoms is important for public health.
This paper is based on a review of studies published between 2002 and 2019 on post-traumatic stress disorder (PTSD) among adult civilian survivors of 9/11 who were directly exposed. The review considered a number of aspects of each published study. These included the study design, timeframe, reported prevalence and persistence of PTSD and conditions that co-occurred with PTSD. several.
This review paper further emphasizes that PTSD continues to be a critical area for understanding survivors’ emotional and physical development after 9/11 and makes recommendation for future research.
Poor mental health (PTSD, depression, or anxiety) has been associated with reduced asthma control among people exposed to the 9/11 World Trade Center attacks. This study investigated whether ad-herence to long-term asthma control medication changed this association. Our data suggest that those who were adherent had poorer asthma control. We found no evidence to show that adher-ence changed the association between poor mental health and reduced asthma control.
Numerous studies have reported elevated levels of chronic mental health conditions in those exposed to the 9/11 World Trade Center attacks. Few studies have examined the confusion or memory loss (CML) or its association with mental health among 9/11 survivors. We investigated CML and its association with having one or more mental health conditions (PTSD, depression, and anxiety) in 10,766 World Trade Center Health Registry enrollees. These enrollees were aged 35–64 at the time of the Wave 4 survey (2015–2016) and had also completed Waves 1-3. Twenty percent of enrollees reported having CML. We also found the likelihood of having CML in-creased with the number of mental health conditions a person reported. Confusion or memory loss experienced by 9/11 survivors may be due in part to the mental health consequences of the 9/11 attacks. Doctors treating 9/11 survivors with mental health conditions should be aware of potential cognitive impairment such as confusion or memory loss.
The association between exposure to the September 11, 2001, attack on the World Trace Center (WTC) and autoimmune disease, a condition that causes responses in the immune system that attack normal body tissue, has been suggested in early research, but remains understudied. Several components of the dust cloud that resulted from the collapse of WTC, such as crystal-line silica, have been associated with systemic autoimmune disease (SAD) . In addition, Post Traumatic Stress Disorder (PTSD), which is associated with 9/11-exposure, has also been shown to be higher in those suffering from SAD. Among 43,133 WTC Health Registry enrollees, 2,786 self-reported having a post-9/11 systemic autoimmune disease. Rheumatoid arthritis was the most frequently reported condition (n = 71), followed by Sjӧgren’s syndrome (n = 22), sys-temic lupus erythematosus (n = 20), myositis (n = 9), mixed connective tissue disease (n = 7), and scleroderma (n = 4). ). Among 9/11 responders, those with intense exposure to the dust cloud had almost twice the risk of systemic autoimmune disease. Non-responders with 9/11-related PTSD had a nearly 3-fold increased risk of SAD. Although this study suggests some as-pects of 9/11 exposure may be associated with SAD, more research is needed to fully charac-terize any possible relationship. Those treating 9/11 survivors and workers should be aware of the possibility this population may be at increased risk of SAD, which is often hard to diagnose.
The association between low socioeconomic standing (SES) and diminished health is one of the most well-described in social epidemiology. However, many of the mechanisms that lead disad-vantaged populations to be more susceptible to many health conditions like asthma compared to more affluent populations are not fully understood. This study examined whether barriers to care, such as lack of money or transportation and not knowing where to go for care, helped explain why enrollees who had lower income, were racial minorities, or who had lower education were more likely to be hospitalized for asthma. Those of lower SES were more likely to experience an asthma-related emergency department (ED) visit. Although the number of barriers to care influ-enced this association, they explained only a small percentage of the overall health disparity of the differences between African American and white individuals and between those with less than a high school diploma to those with at least a bachelor’s degree. However, the association varied by specific barrier to care. Lack of money, insurance, and transportation accounted for up to 11.8%), 12.5% and 4.3% respectively, of the association between SES and number of ED vis-its. Barriers such as lack of childcare, not knowing where to go for care, and inability to find a health care professional contributed to a smaller or no percentage of the association. Health eq-uity, a situation where everyone has a fair and just opportunity to be as healthy as possible, irre-spective of SES, is an important goal for public health authorities. In order to bring it about, we need to better understand the circumstances that are related to poorer health outcomes in vul-nerable populations.
Few studies have looked into the long-term health effects of frequent moves within and across neighborhoods. This study examined how often people moved and displacement from a neighborhood over 12 years. Displacement was when people moved to a poorer neighborhood. We found that frequent moves was not associated with having a higher risk of developing diabetes or high blood pressure.
Hearing tests are used to assess changes in hearing and report worker health problems. This study developed tables that adjusted for age. It validated the tables using data on firefighter and emergency medical service workers from a large U.S. survey. Different trends were observed among people identifying with non-Hispanic Black race/ethnicity. The population-based tables matched well with changes over time in hearing sensitivity. The tables provide a good replacement for those used by current U.S. regulations. They address a broader range of worker ages, account for differences in hearing sensitivity by race/ethnicity and have been validated for men.
Air pollution was reported as the most common trigger of asthma among people exposed to the WTC disaster. This study examined the relationship between air pollution and asthma control and how asthma control relates to the person’s perceived well-being. Our study suggests that reducing air pollution exposure may improve the health of WTCHR enrollees with asthma.
Studies addressing specific research questions may necessitate selecting a random sample from different eligibility groups of the 9/11-exposed enrollees for estimating the population parameters. Sampling strategies are proposed and compared using overlapping eligibility groups of enrollees, in terms of their bias and efficiency.
In this paper, researchers looked to see if certain factors were related to having confusion or memory loss. Confusion or memory loss may be related to cognitive decline. The sample included enrollees who were middle aged. We believed that those with more indicators of cognitive reserve would be less likely to experience confusion or memory loss. Our analysis found this to be true. Education level was a key factor for cognitive reserve, but other factors such as physical activity and social support were important as well.
This study of World Trade Center tower survivors found that 13% of them had PTSD. Two thirds of those with PTSD also had depression. Those with lower self-efficacy and greater WTC exposure were more likely to have both PTSD and depression. Targeting the processing of experiences and enhancing self-efficacy may be an effective way to treat those with PTSD and depression.
This is the first report about Pulmonary Fibrosis (PF) among WTC responders. We counted 73 self-reported PF cases in a group of 19,300. Those exposed to a medium level of WTC dust or higher reported having PF more often than those with low exposure. Long-term follow-up with health check-ups is needed for this condition.
The study found that enrollees with 9/11-related PTSD who then experienced Hurricane Sandy increased their chances of future 9/11-related PTSD. Those with lower optimism after Sandy had a higher risk for 9/11-related PTSD. This shows the need to explore mental health for this group.
This study found nearly half of enrollees of 9/11-exposed reported having developed one or more of the health conditions. Participants with PTSD or depression reported the worst health-related quality of life. They also had the highest levels of unmet need for mental health care. This suggests increased efforts to reach this group are needed.
Takemoto E, Brackbill R, Martins, S, et al. Post-Traumatic Stress Disorder and Risk of Prescription Opioid Use, Over-Use, and Misuse Among World Trade Center Health Registry Enrollees, 2015-2016. Drug Alcohol Depend, 210, 107959.
Post-traumatic stress disorder (PTSD) has been associated with increased mortality, primarily in studies of veterans. This is the first study to examine whether 9/11-related probable-PTSD measured repeatedly over the life course of enrollees following exposure is associated with an increased risk of mortality (all-cause, cardiovascular and external-cause) over 13 years of follow-up among 9/11 exposed responders and civilians. We studied 63,666 enrollees of the World Trade Center Health Registry and found that PTSD was associated with increased risk of mortality and the associations were strengthened when considering PTSD overtime compared with a single PTSD assessment at study entry. Our findings underscore the importance of long-term efforts to identify and treat those at risk of developing PTSD following a traumatic experience.
The World Trade Center attacks on September 11th, 2001 (9/11) have been associated with the subsequent development of chronic diseases such as asthma, Post Traumatic Stress Disorder, heart attack, stroke, cancer, and autoimmune disease. Few studies have investigated the burden of unexplained physical health issues, or “somatic symptoms,” on 9/11 victims, or the relationship of such symptoms to exposure to the 9/11 attacks. In this study, we found that twenty-one percent of subjects had a “very high” burden of somatic symptoms, which is a greater rate compared to those in the general population, or populations who were not exposed to mass disasters (2-7%). We found that the level of somatic symptoms increased as the severity of reported 9/11-injury and psychological distress increased. In conclusion, we determined that victims of the 9/11 attacks suffer from a substantial burden of somatic symptoms, which are associated with physical and psychological consequences of exposure to the attacks. When designing treatment protocols for individuals exposed to complex man-made disasters like 9/11, healthcare professionals should consider both physical and mental health treatment approaches.
Among veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with the use and misuse of prescription opioids but less is known about other populations. This study sought to determine if PTSD following exposure to the World Trade Center (WTC) disaster is associated with the recent use, over-use, or misuse of prescription opioids. Among individuals exposed to the World Trade Center disaster, three categories of post-9/11 PTSD were derived: never, past, and current. Self-reported opioid use outcomes were defined as (yes/no): recent use (use of a prescription opioid), over-use (use of a prescribed opioid in a manner other than prescribed) and misuse (use of a prescription opioid prescribed to someone else). Individuals with past and current PTSD had an increased risk of all three opioid-related outcomes compared to those in the never PTSD group. Our study demonstrated that both past and current 9/11-related PTSD is a risk factor for opioid use and misuse among the general population, findings which may assist in improving screening and surveillance measures.
The health consequences of the 9/11 World Trade Center (WTC) terrorist attacks are well documented, but few studies have assessed the disaster’s impact on employment among individuals exposed to the disaster. Early retirement is an important factor to consider for economic assessments, as it can strongly affect one’s well-being (such as post-retirement income) for the remainder of one’s life. This study examined the association between 9/11-related health conditions and early retirement among residents and workers (N=6,377) who resided and/or worked near the WTC site on 9/11. It also looked at the association between such conditions and post-retirement income loss. The study data were from the WTC Health Registry, longitudinal health surveys in 2003–2004 and 2006–2007, and the 2017–2018 Health and Employment Survey. We found that residents and area workers with more physical health conditions resulting from 9/11, especially when simultaneously present with posttraumatic stress disorder (PTSD), were more likely to retire before age 60 than those with no conditions. For retirees, having PTSD or PTSD in addition to any number of physical conditions increased the odds of reporting substantial post-retirement income loss. Disaster-related outcomes can negatively impact aging individuals in the form of early retirement and income loss. Long-term effects of major disasters must continue to be studied.
Exposure to the events on 9/11 is associated with greater incidence of poor mental health, asthma diagnosis, and poor asthma control. Prior research has shown mental health conditions, such as anxiety, depression, and PTSD, are associated with poor adherence to asthma medication protocols. To examine these complicated relationships, this study used self-reported long-term medication adherence data see if non-adherence explained part of the relationship between diminished mental health and less asthma control. The study population was composed of participants of the World Trade Center Health Registry Cohort who identified themselves as asthmatic after the disaster and who were currently prescribed a long-term asthma control medication.
Contrary to the original hypothesis, this study found that enrollees with mental health conditions who were better at adhering to their medication regimen had slightly worse control of their asthma than those with poor medication adherence. This finding suggests that in this population, the relationship between poor mental health and worse asthma control may not be explained medication adherence. There are a few possible explanations for these paradoxical results. For example, severe asthmatics may adhere better to their prescribed medication protocols because they are highly symptomatic and stick closely to their regimen to reduce symptoms. Therefore, the association between adherence and asthma control among the WTC-exposed population may have once been positive (that is greater adherence was associated with greater asthma control), but at some point, reversed. Over the several years of the study period (2002-2016), patients who were more responsive to treatment improved, whereas other patients, whose symptoms were less responsive to treatment, did not.
The persistence of symptoms more than a decade after the event also raises questions about the physiology of WTC-related asthma and whether corticosteroid-based therapy, medication that is used to treat severe asthma, may be incompletely effective in the population we studied. Asthma can be caused by a variety of inflammatory pathways. Air-born irritant-induced asthma, such as the WTC-related asthma, may likely be a new and ill-defined asthma type, and not responsive to current therapies. There is also the possibility that because symptoms are often non-specific and potentially misdiagnosed, that some enrollees are being treated for, but do not, in fact, have asthma. Asthma is a complex condition and may be an overly broad term that describes related but separate diseases.
This paper reports on study examining determinants of asthma presence among World Trade Center (WTC) rescue and recovery workers, who were present at different proximities to the attacks on September 11th . The study consisted of WTC workers with asthma who were en-rolled in the Mount Sinai Hospital, Northwell Health Queens, or New York University Langone Medical Center WTC Health Programs. Study participants completed the Asthma Trigger Inven-tory (ATI) questionnaire, a validated self-reported survey with 32 questions that assess an individual’s asthma triggers. This analysis included 372 study participants with complete data on asthma triggers and psychological diagnoses. The most common triggers were air pollution and general allergens, such as mold, mites, and house dust, reported by 75%and 68% of participants, respectively. Other triggers included psychological (21%), physical activity (53%), and infections, such as viral upper respiratory syndromes, (52%), We found that psychological triggers account for a large proportion of the variability in control of asthma symptoms and asthma-related quality of life. Results from this study suggest that greater attention is needed to the perception of asthma triggers among WTC rescue and recovery workers who present both asthma and psychological conditions.
Exposure to disasters is associated with long-term outcomes that impact one’s quality of life in numerous ways. In epidemiological research, quality of life refers to a person or group of peoples’ general well-being and satisfaction with the various aspects of their lives including physical health, family, education, employment, and finances. Quality of life among survivors of the terrorist attacks on the World Trade Center (WTC) is poorly understood, even with numerous studies showing that both mental and physical health conditions, strong predictors of quality of life, associated with the disaster can persist for years. In this study, we tried to dig deeper into the is-sue of the quality of life among 9/11 survivors by comparing life satisfaction and limited activity days among WTC Health Registry enrollees who did and did not endure physical injuries on 9/11. We used a “mixed-methods” approach for our study’s methodology meaning we performed both a statistical, or “quantitative,” analysis and a “qualitative” analysis of free text response left by enrollees at the end of the W4 survey. For the quantitative portion of the analysis, we examined the differences in life satisfaction and number of limited activity days in the last 30 days (i.e. at the time the survey response were given) between those with and without injuries using a statistical method called a “multivariable logistic regression.” For the qualitative portion of the analysis, we used a multi-round textual analysis to determined several themes embedded in the free-text comments and compared themes left by those with and without injuries. Textual themes identified in this analysis included, “emotional trauma/depressed/anxious,” “fear of future,” and, “I have moved on.” Our key findings in the quantitative analysis were that, compared to those who were not injured, those who sustained injuries on 9/11 were more likely to report being unsatisfied with their life and have 14 or more limited activity days in the last 30 days. Among those who were injured, being partially or completely prevented from working increased the likelihood of being unsatisfied with life and having 14 or more limited activity days. In the qualitative analysis, the emotional trauma experienced on account of exposure to 9/11 was a major and common theme, irrespective of injury status. Those who were injured on 9/11 were more likely to leave comments that fell into the theme of “anger/lack of recognition/appreciation,” describe substance use or abuse, and write about financial or healthcare access issues.
The use of quantitative and qualitative analysis provided a more nuanced picture of the long-term effect of being injured on 9/11 on the present-day quality of life for WTC Health Registry enrollees. Early treatment for disaster-related injuries, as well as the identification and treatment of mental health conditions among those exposed to disasters, may improve long-term quality of life-related outcomes.
A previous publication from the World Trade Center (WTC) Health Registry (Registry) on a cohort of individuals exposed to the events of the WTC disaster of September 11th , 2001 (9/11), found that exposure to the dust cloud, an environmental hazard resulting from the collapse of the WTC towers, among those who evacuated damaged and destroyed buildings was associated with self-reported hearing problems. A more recent publication from the Registry reported that among rescue and recovery workers, higher levels of WTC exposure – defined using a composite score based on one’s location on the morning of 9/11, date of arrival at the WTC site, total days worked a the WTC site, and specific time periods worked on the debris pile at the WTC site- and being unable to hear in the dust cloud were both independently associated with more than double the odds of hearing problems. For our latest study, we used responses to the first two Registry surveys to examine the association between exposure to the dust cloud and persistent hearing loss among survivors (n = 22,741). The prevalence of post-9/11 persistent hearing loss among WTC survivors was 2.2%. Those who were in the dust cloud and unable to hear had three times the odds of reporting persistent hearing loss. Survivors with persistent sinus problems, headaches, Post Traumatic Stress Disorder, and chronic disease histories had an increased prevalence of reported hearing problems compared to those without symptoms or chronic-health problems. Public health officials should consider including questions about hearing trouble in surveys following future disasters involving chemical, dust, or blast exposures. Audiometric screening is also recommended as part of ongoing medical surveillance for subsequent health effects.
This was a study of the longitudinal predictors of depression among a cohort exposed to 9/11 attacks. We found that depression more common among those with history of PTSD (56.2%) vs. without (5.6%). Low income, unemployment, and low social support increased the risk of depression among those with and without a history of PTSD. In general, the risk factors for depression were similar for those with and without a history of PTSD.
Have more deaths occurred among persons directly exposed to the 9/11 disaster than expected, based on comparison to the general New York City population? The WTC Health Registry identified the number and causes of death among Registry enrollees between the years of 2003-2014 via linkage to the National Death Index. We compared this number to the expected number of deaths based on mortality rates in the general NYC population. Overall, mortality among WTC Health Registry enrollees was not elevated. In fact, fewer deaths occurred than would be expected, based on comparison to the general NYC population. Registry enrollees had fewer cardiovascular and respiratory deaths than expected based on NYC reference rates. However, there were more deaths due to suicide among rescue-recovery workers than expected; these deaths mostly occurred among workers who did not perform rescue and recovery work in their usual, pre-9/11 work. There were also more deaths than expected due to non-Hodgkin’s lymphoma among community members. Even though the number of deaths overall was not elevated among Registry enrollees, there appears to have been an increased risk of death associated with higher levels of 9/11-related exposures. The Registry will continue to follow the numbers and causes of death among enrollees.
Boffeta, P, Zeig-Owens R, Wallenstein S, Li J, Brackbill RM, Cone JE, Farfel MR, Holden W, Lucchini R, Webber MP, Prezant D, Stellman SD, Hall CB. Response to Soskolne . Am J Ind Med. 2017 April; 60(5): 512. doi:10.1002/ajim.22713 [Letter] PMID: 28409859
The flooding after Hurricane Sandy (Sandy) resulted in conditions that could potentially lead to an increased risk of lower respiratory symptoms (LRS). This study sought to determine the relationship between Sandy-related exposures and post-Sandy LRS in a population with prior exposure to the World Trade Center disaster. The Sandy-related inhalational exposures examined were: 1) reconstruction exposure; 2) mold or damp environment exposure; and 3) other respiratory irritants exposure. Over one-third of participants reported post-Sandy LRS. Enrollees reporting any of the exposures were twice as likely to have post-Sandy LRS. There was a dose-response relationship between the number of Sandy-related exposures reported and post-Sandy LRS. This study shows that post-hurricane clean-up and reconstruction exposures can increase the risk for LRS. Public health interventions should emphasize the importance of safe remediation practices and recommend use of personal protective equipment.
Hearing loss is a concern among World Trade Center Health Registry (WTCHR) enrollees. A previous study of enrollees who were WTC Tower survivors found that exposure to the cloud of dust and debris generated by the collapse and fires in the WTC Towers and surrounding buildings was associated with reported hearing problems. More recently enrollees have contacted the Registry to discuss concerns about hearing loss. Possible WTC-related causes for hearing loss include ruptured ear drums, head trauma from injuries, toxic exposures in smoke, dust and debris, or noise exposure. Our recently published study found that among those rescue and recovery workers without pre-9/11 hearing problems, 4.4% reported persistent hearing problems in 2006-2007. Men reported more hearing problems than women, and on average, those with hearing problems were older. The prevalence of hearing problems increased with increased numbers of WTC-related environmental hazards. Workers who reported being unable to hear in the dust cloud had over 2 times the odds of reporting hearing problems, compared to workers not in the dust cloud. This study has led the Registry to partner with the Fire Department of the City of New York in a study of hearing function before and after 9/11/01 among firefighters and Emergency Medical Service workers. Future disaster follow-up should include surveillance evaluation of hearing loss among responders.
Miller-Archie SA, Jordan HT, Alper H, et al. J Asthma. 2017;6:0.
Exposure to the World Trade Center attacks on September 11, 2001 has been linked with new and worsening asthma. In addition, conditions that commonly occur with and that can exacerbate asthma, namely gastroesophageal reflux symptoms (GERS) and posttraumatic stress disorder (PTSD), have also been associated with the 9/11 attacks. However, little is known about hospitalizations for asthma within this population. The World Trade Center Health Registry matched its records with New York State hospitalization records to identify enrollees who had been hospitalized for asthma between September 11, 2001 and December 31, 2010. Of the 11,471 enrollees with asthma, 406 (3.5%) had been hospitalized at least once for asthma, for a total of 721 hospitalizations. Among enrollees who were first diagnosed with asthma before 9/11, those with PTSD or GERS had twice the rate of asthma hospitalizations, after accounting for age, sex, education, smoking, and 9/11 exposure. Enrollees who were black or Latino and those with less than a college degree also had an increased rate of hospitalization. Medical management of comorbid physical and mental health conditions may play an important role in preventing hospitalizations for asthma.
Alper HE, Yu S, Stellman SD, Brackbill RM. Inj Epidemiol. 2017;4(1):17.
Many people exposed to the September 11, 2001 terrorist attacks developed chronic diseases years later, but little is known about the association between chronic disease and exposure to the 9/11 attacks (e.g. injury, dust cloud), among those exposed exclusively or mainly on the day of the attacks. This study investigated the association between heart disease and injury, and between asthma/other lung diseases and dust cloud exposure, among those whose exposure occurred on 9/11 and not afterwards. Heart disease exhibited a substantial and significant association with number of injury types sustained on 9/11, while asthma and other lung diseases were significantly associated with intense dust cloud exposure on 9/11. These results suggest the need for continued monitoring of 9/11 exposed persons by medical providers.”
Gargano L, Locke S, Brackbill RM. 2017;19(2):358-65.
Previous Registry findings showed that exposure to the 9/11-disaster was associated with behavior problems in adolescents 6-7 years after the event. In addition, 9/11-related post-traumatic stress disorder (PTSD) among parents has been associated with behavior problems in their adolescent. This study examined behavior problems in adolescents 10-11 years after 9/11. Even 10-11 years later, adolescents with moderate/severe 9/11-exposure were more likely to have behavior problems. Adolescents whose parent had comorbid 9/11-related PTSD and at least one other chronic health condition were more likely to have behavior problems then adolescents whose parents had 9/11-related PTSD only or chronic health condition only. Parents who reported 14 or more poor mental health days were more likely to have an adolescent with behavior problems.
Yu S, Alper HE, Nguyen AM, et al. BMC Med Res Methodol. 2017;17(1):77.
Using the World Trade Center Health Registry’s Wave 4 survey data, this study evaluated the effectiveness of a monetary incentive in improving the response rate five months after survey launch, and assessed whether or not response completeness was compromised due to incentive use. We found that the likelihood of returning a survey increased by 30% for those who received an incentive offer (AOR=1.3, 95% CI: 1.1, 1.4), and the incentive increased the number of returned surveys by 18%. Moreover, our results did not reveal any significant differences on response completeness between those who received an incentive offer and those who did not. This study showed the value of offering a monetary incentive as an additional refusal conversion strategy.
Jordan H, Friedman SM, Reibman J, et al. Occup Environ Med. 2017;74(6):449-55.
Many lower Manhattan community members who were exposed to dust and fumes during the 9/11/2001 World Trade Center attacks have persistent lower respiratory symptoms, but little is known about underlying pulmonary function or risk factors for symptom persistence. We conducted in-depth interviews and tests of pulmonary function among 545 community members enrolled in the WTC Health Registry in 2008-2010, and a follow-up exam in 2013-2014. Most participants with persistent post-9/11-onset lower respiratory symptoms in 2013-2014 had evidence of peripheral airway dysfunction, despite having normal spirometry results. Peripheral airway dysfunction and 9/11-related posttraumatic stress disorder were each independently associated with the persistence of lower respiratory symptoms 12-13 years after the attacks. These findings underscore the importance of coordinating mental and physical health care for survivors of complex environmental disasters, and suggest that peripheral lung function assessment should be included in the evaluation of lower respiratory symptoms after such exposures.
Gargano L, Dechen T, Cone JE, et al. Journal of Urban Health. March 2017.
Poor school-functioning can be a consequence of poor parent or adolescent mental health or adolescent behavior problems. This study examined the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on school-functioning. Family WTC-exposure was associated with UHCN only by acting through parental mental health. Adolescent mental health, behavioral problems, UHCN, and parental mental health all effected school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health and behavioral problems, as efforts to address any of these alone may not be sufficient.
Welch A, Zweig K, McAteer J, et al. Am J Prev Med. 2017;52(2):192-98.
Some people who directly experienced the September 11 attacks in NYC are still suffering from serious mental health problems, including PTSD and excessive alcohol consumption. Data from a 2015-2016 study conducted on over 28,000 WTC Registry enrollees over the age of 18 showed that 25% reported binge drinking in the past month. This is 1.5 times greater than the proportion of NYC adults reporting binge drinking. Of those who said they had engaged in binge drinking, more than one-third reported high intensity binge drinking which means they had more than eight drinks on one occasion. People with PTSD were two times more likely to binge drink with high intensity than to not binge drink at all compared to people without PTSD. In this study, certain groups were more likely to report high intensity binge drinking: People with PTSD, those who participated in rescue and recovery work, and those with 9/11-related injuries and other traumatic exposures. It is important therapy addresses both PTSD symptoms and excessive alcohol use. Policy strategies aimed at reducing access to and the consumption of alcohol are other ways to help reduce binge drinking. Improving access to treatment of PTSD and alcohol use will help people who binge drink and have PTSD lead happier and healthier lives.
Gargano LM, Thomas PA, Stellman SD. Pediatr Res. 2017;81(1-1):43-50.
Little is known about asthma control in adolescents who were exposed to the World Trade Center (WTC) attacks of 9/11/2001 and diagnosed with asthma after 9/11. This study examined asthma and asthma control 10-11 years after 9/11 among exposed adolescents. Similar to previous studies, post 9/11 asthma was associated with dust cloud exposure on 9/11. Poorly/very poorly controlled asthma was significantly higher among adolescent living in a household with income of ≤$75,000, had unmet healthcare needs, and who screened positive for at least one mental health condition. The impact of having at least one mental health condition on the level of asthma control was substantially greater in females than in males.
Gargano LM, Thomas PA, Stellman. SD Journal of Child & Adolescent Substance Abuse. 2017;26(1):66-74.
This study examined prevalence of and factors associated with substance use 10-11 years post-9/11 among adolescents in the World Trade Center Health Registry. Adolescents who witnessed a disturbing event on 9/11 were twice as likely to report ever drinking and almost three times as likely to have ever used marijuana. Among those ≥5 years of age on 9/11, fear for personal safety on 9/11 was significantly associated with having ever smoked cigarettes, ever drank, and ever used marijuana. Intervention and education for adolescents particularly focused on substance use and coping strategies, may be warranted after large-scale disasters.
Gargano Lisa, Gershon RR, Brackbill RM. PLoS Curr. 2016;8.
Interviews with person injured on 9/11 found that even after the injury has healed, injured disaster survivors continue to have long-term health impacts from their experience. Some injured disaster survivors report having serious physical and mental health problems, economic problems due to loss of livelihood, limited sources of social support. A few survivors reported profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery.
Friedman SM, Farfel MR, Maslow C, et al. Occup Environ Med. 2016; 73(10);676-84.
Many of our studies have found that people who were exposed to the 9/11 disaster have lower respiratory symptoms persisting five to six years after 9/11. We wanted to investigate if Registry enrollees continue to experience the same symptoms ten or more years later.
These symptoms include:
More than 12% of 18,913 adult enrollees reported lower respiratory symptoms during the 30 days prior to completing the surveys. Half of those with persistent lower respiratory symptoms screened positive for one or more mental health conditions such as PTSD, depression, or anxiety. Lower respiratory symptoms accompanied by mental health conditions decreased quality of life persistent for at least ten years after 9/11. We recommended that WTC exposed adults continue to be monitored for both respiratory and mental health conditions and treated for both categories of illness.
Li J, Brackbill RM, Jordan HT, et al. Am J Ind Med. 2016;59(9):805-814.
Increased rates of GERS, asthma, and posttraumatic stress disorder (PTSD) have been frequently reported in those exposed to 9/11. Few studies have explored the interrelationships among these three conditions. Our study found that asthma and PTSD were each independently associated with both the persistence of GERS that was present at the time of 9/11, as well as development of GERS in persons without a prior history. Posttraumatic stress symptoms may also play a role in the association between asthma and late-onset GERS. These findings suggest that integrated physical and mental care could lessen the longer-term health effects of 9/11.
Yu S, Brackbill RM, Locke S, et al. Am J Ind Med. 2016;59(9):731-741.
This study focused on the economic impact of the 9/11 terrorist attacks. We looked at the association between 9/11-related chronic health conditions with or without PTSD and early retirement and job loss. A total of 7,662 non-uniformed rescue/recovery workers, such as volunteers, construction workers, healthcare staff, finance, and environmental services workers were studied. We found that workers with chronic conditions were more likely to experience early retirement and job loss, and the likelihood increased considerably when the worker also had PTSD. Disasters like 9/11 terrorist attacks have a large ripple effect on one’s overall well-being through health, employment, and earnings. Future evaluation of disaster impact should extend beyond the direct and short-term health consequences and include its long-term impact on labor force.
Gargano LM, Nguyen AM, DiGrande L, et al. Am J Ind Med. 2016;59(9):742-51.
This study compared the current mental health status of persons who were in the World Trade Center (WTC) towers, other surrounding buildings, or on the street the morning of the September 11th terrorist attacks. Those in the WTC towers were at increased risk for post-traumatic stress disorder (PTSD) and frequent binge drinking. Infrastructure and behavioral barriers experienced during evacuation were significantly associated with PTSD. Understanding the effects of disaster-related evacuation barriers on the long-term mental health status of survivors can help in the planning of continuing post-disaster treatment.
Li J, Brackbill RM, Liao TS, et al. Am J Ind Med. 2016;59(9):709-21.
Since its inception, cancer surveillance has been a priority for the World Trade Center Health Registry. The Registry first examined cancer incidence from 2003 to 2008 in a study that found more cases than expected of prostate cancer, thyroid cancer, and multiple myeloma among rescue/recovery workers enrolled in the Registry, compared to the general New York State population. The article “Ten-year cancer incidence in rescue/recovery workers and civilians exposed to the September 11, 2001 terrorist attacks on the World Trade Center” presents findings from a follow up study of cancer incidence.
The study found that for all cancer sites combined from 2007-2011, there were 11 percent more cancer cases than expected among rescue/recovery workers, and 8 percent more among civilian survivors compared with the New York State general population. Prostate and thyroid cancer remained elevated among rescue/recovery workers. There were also small, but higher than expected, incidence of skin melanoma in rescue/recovery workers and non-responder civilian survivors. Among civilian survivors, the study found elevated incidence of female breast cancer and non-Hodgkin’s lymphoma. The findings also provide limited evidence for a causal link between 9/11 exposure and cancer. These findings need to be substantiated by additional follow up studies over time.
Cone JE, Osahan S, Ekenga CC, et al. Am J Ind Med. 2016;59(9):795-804.
To evaluate the risk of asthma first diagnosed among Staten Island landfill and barge workers, we conducted a survey and multivariable logistic regression analysis regarding the association between Staten Island landfill and barge-related work exposures and the onset of post-9/11 asthma. Asthma newly diagnosed between 9/11/01-12/31/04 was reported by 100/1836 (5.4%) enrollees. Jobs involving sifting, digging, welding, and steel cutting, enrollees with high landfill/barge exposure index scores or who were police and sanitation workers, and enrollees with probable posttraumatic stress disorder all had increased odds ratios for new-onset asthma.
Post-9/11 asthma cumulative incidence among Staten Island landfill/barge workers was similar to that of other WTC disaster rescue and recovery workers.
Schwarzer R, Cone JE, Li J, et al. BMC Psychiatry. 2016;16:201.
This paper examined the relationship between initial exposure levels, long-term PTSD symptoms, and subsequent emotional support among police responders. The study population included police responders who had reported their 9/11 exposure levels at Wave 1 (2003/4), provided three waves of data on PTSD symptoms using the 17-item PCL scale, and rated their received emotional support at Wave 3 (N=2,204, 1,908 men, 296 women, mean age: 38 years at exposure). A second-order growth curve reflected a PTSD symptom trajectory which was embedded in a structural equation model, with exposure level specified as an exogenous predictor, and emotional support specified as an endogenous outcome. Exposure had a main effect on mean symptom levels (intercept) across three waves but it made no difference in changes in symptoms (slope), and no difference in emotional support. The symptom trajectory, on the other hand, had an effect on emotional support. Its intercept and slope were both related to support, indicating that changes in symptoms affected later emotional support. Initial trauma exposure levels can have a long-term effect on mean symptom levels. Emotional support is lower in police responders when PTSD symptoms persist over seven years, but becomes higher when reduction in symptoms occurs.
Brown S, Gargano LM, Parton H, et al. Disaster Med Public Health Prep. 2016 Apr 21:1-9.
This study examined factors associated with evacuation and evacuation timing during Hurricane Sandy. Among respondents who evacuated for Hurricane Sandy (51%), 24% had evacuated before the storm. Those more likely to evacuate knew they resided in an evacuation zone, had evacuated during Hurricane Irene, or reported pre-Sandy community cohesion. Evacuation was less likely among those who reported being prepared for an emergency. For evacuation timing, evacuation before Hurricane Sandy was less likely among those with pets and those who reported 14 or more poor physical health days. Higher evacuation rates were observed for respondents seemingly more informed and who lived in neighborhoods with greater social capital. Improved disaster messaging that amplifies these factors may increase adherence with evacuation warnings.
Bowler RM, Kornblith ES, Li J, et al. Am J Ind Med. 2016 Jun;59(6):425-36. doi: 10.1002/ajim.22588. Epub 2016 Apr 20
We examined comorbidity of PTSD, depression, and/or anxiety among police enrollees (N=1,884) from the WTC Health Registry. Categorized into four groups based on comorbidity of PTSD, depression, and anxiety. DSM-IV diagnostic criteria for PTSD were used. Depression (PHQ-8) and anxiety (GAD-7) were assessed with standardized psychometric inventories. Multinomial logistic regression was used to identify putative risk factors associated with comorbidity of PTSD. Of 243 (12.9% of total) police with probable PTSD, 21.8% had probable PTSD without comorbidity, 24.7% had depression, 5.8% had anxiety, and 47.7% had comorbid depression and anxiety. Risk factors for comorbid PTSD, depression, and anxiety include being Hispanic, decrease in income, experiencing physical injury on 9/11, experiencing stressful/traumatic events since 9/11, and being unemployed/retired. Nearly half of police with probable PTSD had comorbid depression and anxiety.
Welch AE, Caramanica K, Maslow CB, et al. J Trauma Stress. 2016 Apr;29(2):158-66. doi: 10.1002/jts.22090. Epub 2016 Mar 8.
The majority of the hundreds of thousands of people directly exposed to the September 11th terror attacks in NYC were civilians and were not involved in rescue/recovery work. Because earlier studies showed that PTSD was one of the most common health conditions up to 6 years after 9/11, we examined longer-term patterns of PTSD symptoms over a nine year period among 17,000 civilians enrolled in the WTC Health Registry. Most civilians had few or no PTSD symptoms; however, one in four had PTSD at some point during the study period. Some people with PTSD had symptoms that improved, however most had symptoms that either persisted or got worse over time. PTSD that persisted or worsened was more common among enrollees with low education and social support, or who had high WTC exposure, were unemployed or were unable to get the mental health care they needed.
Boffetta P, Zeig-Owens R, Wallenstein S, et al. Am J Ind Med. 2016 Feb;59(2):96-105. doi: 10.1002/ajim.22555. Epub 2016 Jan 4.M
This was a review of three longitudinal studies of cancer incidence in WTC rescue/recovery worker populations from three WTCHP programs. The review entailed a detailed comparison of the three study populations, follow-up periods, methods of cancer case identification, exposure assessments, data analysis, as well as the similarity in findings, limitations and potential sources of bias. This paper represents an effort to derive valid epidemiologic results about an important health question despite limitations of the underlying data; and suggested a plan to conduct a pooled analysis of merged cohorts of rescue/recovery workers’ cancer incidence, latency and survival to maximize study power, remove overlap among programs, and systemize interpretation of results.
Cone JE, Li J, Kornblith E, et al. Am J Ind Med. 2015 May;58(5):483-93. doi: 10.1002/ajim.22446.
The current study documents the longitudinal trajectories of PTSD in police officers exposed to the WTC attacks at Wave 3 (2011–2012), over 10 years since the WTC attack. We examined the prevalence of probable PTSD at the Wave 3. Probable PTSD was 14.4% (95% CI 13.0–15.9%) at Wave 2 and 12.9% (95% CI, 11.6–14.3%) at Wave 3. Significant predictors of chronic probable PTSD 10 years post-disaster (n = 59/2241, 2.6%) include age 45–69 (aOR 3.16, 95% CI, 1.7–6.0), number of stressful events witnessed on 9/11/01 (aOR 3.00, 1.6–5.8), five or more stressful life events since 9/11/01 (aOR 5.42, 1.9–15.2), and unmet mental health care needs (aOR 6.86, 3.3–14.1). Protective factors include social support (aOR 0.34, 0.1–0.97) and number of close friends or relatives (aOR 0.92, 0.87–0.98). Chronic probable PTSD among police responders continues to be a significant problem, associated both with intervening stressful life events and unmet mental health care needs.
Jordan HT, Stellman SD, Reibman J, et al. Asthma. 2015;52(6):630-7. doi: 10.3109/02770903.2014.999083. Epub 2015 May 22.
This study of approximately 2,500 WTC Health Registry enrollees who were diagnosed with asthma between 9/11 and the end of 2003 found that only about one third of participants had well-controlled symptoms in 2011-12. The factors that were most closely tied to poor asthma control were co-existing mental health conditions. Gastroesophageal reflux and obstructive sleep apnea were also associated with poor control of asthma. These results show that people with 9/11-related asthma continue to experience symptoms a decade after the attacks, and emphasize the importance of integrating care for 9/11-related mental and physical health conditions.
Gargano LM, Caramanica K, Sisco S, et al. Disaster Med Public Health Prep. 2015 Jun 15:1-9.
This study looked at the level of preparedness for Hurricane Sandy in the 9/11-exposed population, and the relationship between preparedness and disaster-related and non-disaster-related characteristics. Participants were considered prepared if they reported possessing at least 7 of 8 standard preparedness items such as a 3-day supply of water, food, first aid kit, battery-operated radio, medications, flashlight, personal care and hygiene items, and evacuation plan. Over one-third of the 4496 enrollees who participated in the survey were prepared, with 18.8% possessing all eight items. High levels of 9/11 exposure were associated with being prepared. Future preparedness messaging should target people with low social support networks. Communications should include information on evacuation zones and where to find information about how to evacuate.
Yu S, Brackbill RM, Stellman SD, et al. 2015 Feb 15;8(1):42. doi: 10.1186/s13104-015-0994-2.
A study evaluating non-response bias found that, despite a downward bias in prevalence estimates of health outcomes, attrition from the World Trade Center Health Registry follow-up studies does not lead to serious bias in associations between 9/11 disaster exposures and key health outcomes. These findings provide insight into the impact of non-response on associations between disaster exposures and health outcomes reported in longitudinal studies.
Maslow CB, Caramanica K, Welch AE, et al. J Trauma Stress. 2015 May 19. doi: 10.1002/jts.22011.
This study described the course of PTSD symptoms in a cohort of 9/11 responders by identifying five distinct subgroups on the basis of trajectories of scores on the Posttraumatic Disorder Checklist, administered three times over an 8-9 year period. It identified several 9/11-related exposures associated with high likelihood of following specific trajectories, and assessed the impact of changing life circumstances on the course of each trajectory. Responders with higher levels of exposure were more likely to follow less favorable trajectories than were responders with less exposure. Within trajectory groups, responders who endured more adverse personal circumstances during the study period had higher scores than did those with more favorable circumstances. This study highlights the need for immediate and continued periodic screening for both mental health effects of disasters and circumstances that may affect the course of those effects.
Caramanica K, Brackbill RM, Stellman SD, Farfel MR. Compr Psychiatry. Int J Emerg Ment Health. 2015;17(1):356-362.
The Registry provided a sampling pool for a survey of the experiences and physical and mental health of persons directly affected by Hurricane Sandy in the New York City (NYC) metropolitan area in late October 2012; a total of 4,558 Hurricane Sandy surveys were completed from April 10-November 7, 2013. After exclusions for missing data, the final sample included 2,214 (53.5%) respondents from FEMA-defined inundation zones and 1,923 (46.5%) from non-inundation zones. PTSD prevalence was higher in the inundation zones (11.3%) and lower in the non-inundation zones (4.4%). The highest prevalence of Sandy-related PTSD was among individuals in the inundation zone who sustained an injury (31.2%), reported a history of 9/11-related PTSD (28.8%), or had low social support prior to the event (28.6%). In the inundation zones, significantly elevated adjusted odds of Sandy-related PTSD were observed among persons with a prior history of 9/11-related PTSD, low social support, and those who experienced a greater number of Sandy traumatic events.
Caramanica K, Brackbill RM, Liao T, Stellman SD. J Trauma Stress. 2014 Dec;27(6):680-8. doi: 10.1002/jts.21972. Epub 2014 Dec 2.
A study of 29,486 adult Registry enrollees conducted 10-11 years post-9/11 found that 15.2% screened positive for probable PTSD at Wave 3, 14.9% for depression, and 10.1% for both. Comorbid PTSD and depression was associated with high 9/11 exposures, low social integration, unemployment for health reasons, and experiencing more than one traumatic life event since 9/11. Comorbid persons experienced poorer outcomes on all PTSD-related impairment measures and symptom duration, life satisfaction, overall health, and perceived unmet mental health care need compared to those with PTSD or depression only.
Brackbill RM, Caramanica K, Maliniak M, et al. MMWR Morb Mortal Wkly Rep. 2014 Oct 24;63(42):950-4.
The study looked at injuries sustained in the first week after Hurricane Sandy hit New York City area on October29, 2012. The degree of flooding in the home or surrounding area was directly related to the occurrence of injury, with 39% of those who evacuated by walking through water or swimming being injured, and 25% of those whose homes were flooded with 3 or more feet of water, regardless of whether they did or did not evacuate. Additionally, the greatest number injuries occurred among persons who had a damaged or destroyed home and attempted to do clean-up or repair work.
Welch AE, Caramanica K, Maslow CB, Cone JE, Farfel MR, Keyes KM, Stellman SD, Hasin DS. Drug Alcohol Depend. 2014 Apr 28. pii: S0376-8716(14)00839-4. doi: 10.1016/j.drugalcdep.2014.04.013.
Many of our Registry enrollees and other exposed persons developed PTSD after 9/11 and as a consequence may be drinking excessively. We looked at the survey responses from about 41,000 Registry enrollees, to examine the relationship between PTSD, extent of exposure to the 9/11 disaster, and frequent binge drinking, which was defined as having five or more drinks on a single occasion on five or more days of the past month. Frequent binge drinking was reported by fifteen percent of those suffering from PTSD, and only six percent of those without PTSD. People with higher levels of exposure to the 9/11 disaster were more likely to report frequent binge drinking than people with lower exposures. We now have a better understanding of the impact of PTSD and different levels of 9/11 exposure on how often people engage in binge drinking.
Miller-Archie SA, Jordan HT, Ruff RR, Chamany S, Cone JE, Brackbill RM, Kong J, Ortega FM, Stellman SD. Prev Med. 2014 May 28. pii: S0091-7435(14)00182-0. doi: 10.1016/j.ypmed.2014.05.016.
A study of over 36,000 Registry enrollees found that those who had PTSD when they joined in 2003-2004 were 30 percent more likely to develop diabetes six to eight years later than people without PTSD. One explanation is that chronic stress reactions caused by PTSD can, over time, cause the body’s cells to become resistant to insulin, causing sugar to build up in the bloodstream. PTSD has also been associated with unhealthy behaviors including poor diet and physical inactivity, both of which may increase the risk of developing diabetes.
Ghuman SJ, Brackbill RM, Stellman SD, et al. BMC Public Health. 2014 May 22;14(1):491.
A study investigating the mental health care needs of 30,000 Registry enrollees 10 to 11 years after 9/11 found: over 15 % reported having PTSD, nearly 15% percent experienced depression, and 10% percent had both conditions.
Enrollees who reported having both PTSD and depression were more likely to have increased 9/11 exposure, be unemployed, have lower social support and quality of life and have more unmet mental health care needs. It is common for traumatized populations to suffer from both PTSD and depression; the combination is often associated with functional impairment, greater symptom severity and disability.
Brackbill RM, Cone JE, Farfel MR, Stellman SD. American Journal of Epidemiology. 2014 Feb 20.
Enrollees with injuries as a result of 9/11, including broken bones, burns, and head trauma, were found to be at increased risk of chronic disease five to six years later. This study included more than 14,000 adult enrollees who reported no previous diagnosis of heart disease, respiratory dis-ease, diabetes or cancer. The nearly 2,000 enrollees who reported more than one type of injury were twice as likely to also report a respiratory illness as those who were not injured. Enrollees with multiple types of injuries and probable post-traumatic stress disorder (PTSD) were three times more likely to report heart disease than those without injuries and PTSD.
Brackbill RM, Farfel MR, Cone JE, Stellman S. Am J Epidemiol. 2013; 177: S15.
Jordan HT, Stellman SD, Morabia A et al. Journal of the American Heart Association. 2013 Oct 24;2(5):e000431. doi: 10.1161/JAHA.113.000431.
An exploratory study found that two to six years after the 9/11 disaster, measures of dust exposure, injury on 9/11 and PTSD each were associated with an elevated risk of non-fatal heart disease among adult enrollees.
Stellman SD, Li J. Journal of the American Medical Association. 2013 Apr 3;309(13):1344. doi: 10.1001/jama.2013.2240.
Jordan HT, Osahan SS, Cone JE et al. Journal of Occupational and Environmental Medicine. 2012;54(1):2-3.
Brackbill RM, Stellman SD, Perlman SE et al. Social Science & Medicine. 2013 Jan 3. pii: S0277-9536(12)00839-8. doi: 10.1016/j.socscimed.2012.12.016.
High levels of unmet mental health needs and poor mental health days were reported by adult enrollees with probable PTSD symptoms five to six years after 9/11, especially among those who also reported being diagnosed with a mental health condition. However, those with a mental health condition are a vulnerable group. They were much less likely to use mental health services despite having perceived a need for mental health care.
Friedman SM, Farfel MR, Maslow CB et al. American Journal of Industrial Medicine. 2013 Jun 21. doi: 10.1002/ajim.22217.
A study of 14,388 rescue and recovery workers five to six years after 9/11 found that 40% of those with lower respiratory symptoms and 57 percent of those with likely posttraumatic stress disorder (PTSD) had both types of symptoms. Rescue and recovery workers with this combination, or comorbidity, had more severe illness than responders with respiratory symptoms alone or probable PTSD alone. Responders who were comorbid were about three times more likely to report fair or poor general health, and twice as likely to report being unable to perform usual activities for 14 or more days in the month before completing their 2006-2007 survey. Given the comorbidity of respiratory and probable PTSD symptoms, health care providers are strongly encouraged to address both mental and physical health outcomes among persons exposed to a disaster, such as the 9/11 disaster.
Groeger JL, Stellman SD, Kravitt A & Brackbill RM. Prehospital & Disaster Medicine.2013 Nov 19:1-11.
Schwarzer R, Bowler RM, Cone JE (2013). Anxiety Stress Coping. 2013 Jun 8.
Being socially integrated is regarded as a protective factor enabling people to cope with adversity. This study, based on 2943 police officers, examines Posttraumatic Stress Disorder (PTSD) among officers who responded to the 9/11 terrorist attack on the World Trade Center. A model was specified that uses 9/11 horrific event exposure as a predictor, earlier (Wave 1 WPTSD) response as a mediator, and later (Wave 2 PTSD) response as an outcome, and social integration as a moderator of this relationship. We found a multiplicative relationship between exposure levels and social integration: The higher the exposure level, the more stress responses occur, but this effect was buffered by a high level of social integration. Wave 1 PTSD interacted with social integration on Wave 2 PTSD: The more the police officers were socially integrated, the lower the Wave 2 PTSD score. The findings contribute to the understanding of mediating and moderating mechanisms that result in health outcomes such as posttraumatic stress disorder or resilience.
Stellman SD, Thomas PA, Osahan S et al. Journal of Asthma. 2013 Feb 18.
Respiratory symptoms six to seven years after 9/11 were associated with 9/11 dust cloud exposure in younger children and with behavior problems in adolescents. Other risk factors for respiratory symptoms included living in low-income households.2012
Jordan HT, Miller-Archie SA, Cone JE et al. Preventive Medecine. 2012 Mar 12.
Huang MJ, Li J, Liff JM et al (2012). Journal of Occupational and Environmental Medicine. 2012 Mar 22.
Twelve percent of 42,025 Registry adult enrollees reported post-9/11 skin rash in 2003-04, 16% reported skin rash in 2006-07 and 6% reported it at both times. Among enrollees without PTSD or other psychological distress, increased risk for early skin rash was independently associated with intense dust cloud exposure, damage to the home or workplace, and working at least 31 days at the WTC site.
Li J, Cone JE, Kahn AR et al. Journal of the American Medical Association. 2012 Dec 19;308(23):2479-88.
The Registry’s first cancer analysis found that the overall cancer rate in 2007-2008 among people directly exposed to the 9/11 disaster was not different than that of New York State residents during this period. The study, however, did find small increases in rates of three types of cancer—prostate cancer, thyroid cancer, and multiple myeloma—among rescue/recovery workers during this period. This study analyzed cancer diagnoses among nearly 56,000 adult Registry enrollees who resided in New York State at the time of their enrollment.
Maslow CB, Friedman SM, Pillai PS et al. (2012. American Journal of Public Health. 2012 Apr 19.
A Registry case control study of nearly 800 Lower Manhattan residents and area workers found that both acute and chronic WTC exposures were independently associated with lower respiratory symptoms up to six years after 9/11. The risk for lower respiratory symptoms increased both with the severity of dust cloud exposure and the thickness of dust in the home or workplace.
Nair HP, Ekenga CC, Cone JE et al. (2012). American Journal of Public Health. 2012 Aug 16.
More than 25% of residents, office workers, and passers-by enrolled in the Registry who had either lower respiratory symptoms or probable post-traumatic stress disorder (PTSD) had both conditions five to six years after 9/11. Also, enrollees who had both conditions were much more likely to report 14 days of activity lost in the 30 days before being surveyed than enrollees with one of these conditions.
Welch AE, Caramanica K, Debchoudhury I et al. (2012). BMC Public Health. 2012 Aug 31;12(1):721.
In focus groups with both responders and survivors, participants reported barriers that prevented them from accessing 9/11 services: lack of visibility and accessibility of 9/11 health programs; fear of stigma related to receiving mental health care; unfamiliarity with 9/11-related health conditions; and few referrals from primary care providers.
Antao VC, Pallos LL, Shim YK et al (2011). American Journal of Industrial Medicine. 2011 Sep 19. doi: 10.1002/ajim.21009.
Bowler RM, Harris M, Li J et al (2011). 2011 Dec 27. doi: 10.1002/ajim.22000.
A longitudinal study of nearly 3,000 police responders found that PTSD prevalence doubled from 7.8% in 2003-04 to 16.5% in 2006-7. 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.
Cone JE & Farfel M (2011). Journal of Occupational and Environmental Medicine. 2011;53(6 Suppl):S48-51.
Debchoudhury I, Welch AE, Fairclough MA et al (2011). Preventive Medicine. 2011 Sept 10.
DiGrande L, Neria Y, Brackbill RM et al (2011). American Journal of Epidemiology. 2011;173(3):271-81.
Ekenga CC, Scheu KE, Cone JE et al (2011). BMC Public Health. 2011;11:321.
Friedman SM, Maslow CB, Reibman J et al (2011. American Journal of Respiratory Critical Care Medicine. 2011;184(5):582-9.
Jordan HT, Brackbill RM, Cone JE et al (2011). Lancet. 2011; 378(9794):879-87.
Jordan HT, Stellman SD, Prezant D et al (2011). Journal of Occupational and Environmental Medicine. 2011 Aug 19.
Jordan HT, Miller-Archie SA, Cone JE et al (2011). Preventive Medicine. 2011 Oct 28.
Li J, Brackbill RM, Stellman SD et al (2011). American Journal of Gastroenterology. 2011 Sep 6. doi: 10.1038/ajg.2011.300.
Perlman SE, Friedman S, Galea S et al (2011). Lancet. 2011 378(9794):925-34.
Thorpe LE, Friedman S.(2011). Journal of the American Medical Association. 2011;306(10):1133-4.
Weakley J, Maslow CB. In: Council of State and Territorial Epidemiologists, June 2011. Denver, CO; 2011.
Weisfuse IB, Marsik T, Brackbill RM. (2011). In: Levy BS, Sidel WV, eds. Terrorism and Public Health. 2nd ed. New York, NY: Oxford University Press; 2011:43-66.
Bowler RM, Han H, Gocheva V et al (2010). American Journal of Industrial Medicine, 2010; 53(12):1186-96.
Lipkind HS, Curry AE, Huynh M, Thorpe LE, Matte T. Obstet Gynecol 2010;116:917-925.
Brackbil RM, Hadler JL, DiGrande L, Ekenga CC, Farfel MR, Friedman S, Perlman SE, Stellman SD, Walker DJ, Wu D, Yu S, Thorpe LE. JAMA 2009;302:502-516. [Nominated for the CDC/ATSDR, Charles C. Shepard Science Award]
Murphy J. (2009). American Journal of Public Health. 2009; 99(1): 65-7.
Brackbill RM, Thorpe LE, DiGrande L, Perrin M, Sapp JH, 2nd, Wu D, Campolucci S, Walker DJ, Cone J, Pulliam P, Thalji L, Farfel MR, Thomas P. MMWR Surveill Summ 2006; 55:1-18.
DiGrande L, Perrin M, Thorpe L, et al (2008). Journal of Traumatic Stress. 2008;, 21(3), 264-73.
Farfel M, DiGrande L, Brackbill R, et al (2008). Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2008;85(6),: 880-909.
Lipkind HS, Curry, AE, Huynh M et al (2010). Obstetrics & Gynecology. 2010;116(4):917-925.
Thomas P, Brackbill R, Thalji L, et al (2008 Environmental Health Perspectives. 2008; 116(10):1383-1390.
Murphy J, Brackbill RM, Thalji L., et al (2007). Statistics In Medicine. 2007; 26, 1688-701.
Perrin MA, DiGrande L, Wheeler K, et al (2007). The American Journal of Psychiatry. 2007; 164, 1385-1394.
Wheeler K, McKelvey W, Thorpe L, et al (2007. Environmental Health Perspectives. 2007; 115; 1584-1590.
Brackbill RM, Thorpe LE, DiGrande L, et al (2006). Morbidity and Mortality Weekly Report Sur-veillance Summary. 2006;, 55, 1-18.
A quarterly collection of important health information, social events and ways to connect with other enrollees. Each issue of the World Trade Center (WTC) e-newsletter includes the latest WTC health-related findings, information regarding benefit eligibility and updated Health Registry research, posts from members about upcoming events, interviews with enrollees who share their stories of struggle, triumph and much more.