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Respiratory Health Publications

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2025

  • Association of COVID-19 Severity with Comorbidities: Results from the World Trade Center Health Registry
    • A study looked at whether health problems affected COVID-19 severity among 3,568 people exposed to 9/11. Researchers found that some health problems were linked to longer illness or hospital stays. Among rescue and recovery workers, breathing problems, diabetes, and having several health problems were linked to longer COVID-19 symptoms. Among other exposed people, breathing problems and heart disease were linked to more severe illness. The findings show that past health problems may affect COVID-19 recovery after 9/11 exposure.
    • Yung, J., Kehm, R. D., Li, J., & Cone, J. E. (2025). Association of COVID-19 Severity with Comorbidities: Results from the World Trade Center Health Registry. International Journal of Environmental Research and Public Health, 23(1), 10. https://doi.org/10.3390/ijerph23010010 

2023

  • Association of World Trade Center (WTC) Occupational Exposure Intensity with Chronic Obstructive Pulmonary Disease (COPD) and Asthma COPD Overlap (ACO)
    • A WTC Health Registry study found high exposure to 9/11 was associated with cases of COPD and ACO. The findings suggest that early arrival to the WTC site is a risk factor for the development of COPD in workers with pre-existing asthma. 
    • De La Hoz, R. E., Shapiro, M., Nolan, A., Sood, A., Lucchini, R. G., Cone, J. E., & Celedón, J. C. (2023). Association of World Trade Center (WTC) Occupational Exposure Intensity with Chronic Obstructive Pulmonary Disease (COPD) and Asthma COPD Overlap (ACO). Lung, 201(4), 325–334. https://doi.org/10.1007/s00408-023-00636-4 

2022

  • World Trade Center Health Program best practices for diagnosing and treating chronic obstructive pulmonary disease
    • A study found that exposure to the World Trade Center disaster may cause or worsen chronic lung disease, also known as COPD. The World Trade Center Health Program provides medical care for people with COPD who were affected by 9/11. Treatment follows medical guidelines for diagnosing and managing COPD, including care for long-term breathing problems.
    • Cone, J. E., & De La Hoz, R. E. (2023). World Trade Center Health Program best practices for diagnosing and treating chronic obstructive pulmonary disease. Archives of Environmental & Occupational Health, 78(4), 229–231. https://doi.org/10.1080/19338244.2022.2146040 
  • Long-Term Lower Respiratory Symptoms among World Trade Center Health Registry Enrollees Following Hurricane Sandy 
    • People who were exposed to toxic elements from Hurricane Sandy, had a higher chance of having breathing problems years later. However, their breathing problems became less over time. People who had breathing problems and mental stress from Hurricane Sandy had lasting effects on their health, especially if they didn't have breathing problems before.
    • Locke, S. H., Gargano, L. M., Alper, H. E., & Brite, J. (2022). Long-Term Lower Respiratory Symptoms among World Trade Center Health Registry Enrollees Following Hurricane Sandy. International Journal of Environmental Research and Public Health, 19(21), 13738. https://doi.org/10.3390/ijerph192113738 

2021

  • Respiratory Impedance Measured using Impulse Oscillometry in a Healthy Urban Population
    • 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.
    • Berger KI, Wohllebar M, Goldring RM, Farfel MR, Cone JE, Et al. Respiratory impedance measured using impulse oscillometry in a healthy urban population. ERJ Open Res. 2021;7(1):00560-2020. doi:10.1183/23120541.00560-2020.

2020

  • Asthma-COPD overlap in World Trade Center Health Registry enrollees
    • 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. 
    • Haghighi, A., Cone, J. E., Li, J., & De La Hoz, R. E. (2021). Asthma-COPD overlap in World Trade Center Health Registry enrollees, 2015–2016. Journal of Asthma, 58(11), 1415–1423. https://doi.org/10.1080/02770903.2020.1817935

2019

  • Air Pollution/Irritants, Asthma Control, and Health-Related Quality of Life among 9/11-exposed Individuals with Asthma
    • This study examined the relationship between air pollution and asthma control. They also checked how well people with asthma were doing in terms of their overall health and well-being. The study found that if you're aware of what's causing your asthma symptoms, like air pollution, you can do a better job of managing your asthma. It's important to know how to protect yourself from things that make your asthma worse, like avoiding polluted air, and following the advice on how to stay safe can help make your asthma easier to control.
    • Yung, J., Osahan, S., Friedman, S. M., Li, J., & Cone, J. E. (2019). Air Pollution/Irritants, Asthma Control, and Health-Related Quality of Life among 9/11-Exposed Individuals with Asthma. International Journal of Environmental Research and Public Health, 16(11), 1924. https://doi.org/10.3390/ijerph16111924 
  • Pulmonary Fibrosis among World Trade Center Responders: Results from the WTC Health Registry Cohort
    • 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.
    • Li, J., Cone, J. E., Brackbill, R. M., Giesinger, I., Yung, J., & Farfel, M. R. (2019). Pulmonary Fibrosis among World Trade Center Responders: Results from the WTC Health Registry Cohort. International Journal of Environmental Research and Public Health, 16(5), 825. https://doi.org/10.3390/ijerph16050825
  • 9/11 residential exposures: the impact of World Trade Center dust on respiratory outcomes of lower Manhattan residents
    • Residents of lower Manhattan sustained damage to their homes following the collapse of the Twin Towers on 9/11. The study looked at types of home damage and cleaning practices. Dusting or sweeping without water was linked to the largest number of respiratory problems. These problems included shortness of breath, wheezing, and upper respiratory issues. Residents who suffered home damage were more likely to report respiratory issues compared to those who did not report home damage.
    • Antao, V., Pallos, L., Graham, S., Shim, Y., Sapp, J., Lewis, B., Bullard, S., Alper, H., Cone, J., Farfel, M., & Brackbill, R. (2019). 9/11 Residential Exposures: The Impact of World Trade Center Dust on Respiratory Outcomes of Lower Manhattan Residents. International Journal of Environmental Research and Public Health, 16(5), 798. https://doi.org/10.3390/ijerph16050798

2018

  • Associations between Asthma Triggers, Mental Health Conditions, and Asthma Morbidity among World Trade Center Rescue and Recovery Workers
    • A study of 372 World Trade Center rescue and recovery workers with asthma examined what triggered their symptoms. Air pollution was the most common trigger, reported by 75%, followed by general allergens at 68%. Workers with PTSD or panic disorder reported more triggers, including stress, exercise, pollution, and allergens. These triggers were also linked to poorer asthma control and quality of life. The findings suggest that both mental health and environmental factors can affect asthma after disaster exposure.
    • Morales-Raveendran, E., Goodman, E., West, E., Cone, J. E., Katz, C., Weiss, J., Feldman, J. M., Harrison, D., Markowitz, S., Federman, A., & Wisnivesky, J. P. (2019). Associations between asthma trigger reports, mental health conditions, and asthma morbidity among world trade center rescue and recovery workers. Journal of Asthma, 56(8), 833–840. https://doi.org/10.1080/02770903.2018.1502300 
  • Lower Respiratory Symptoms Associated with Environmental and Reconstruction Exposures after Hurricane Sandy
    • 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.
    • Gargano, L. M., Locke, S., Jordan, H. T., & Brackbill, R. M. (2018). Lower Respiratory Symptoms Associated With Environmental and Reconstruction Exposures After Hurricane Sandy. Disaster Medicine and Public Health Preparedness, 12(6), 697–702. https://doi.org/10.1017/dmp.2017.140 

2017

  • Hospitalizations for asthma among adults exposed to the September 11, 2001 World Trade Center terrorist attack
    • 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.
    • Miller-Archie, S. A., Jordan, H. T., Alper, H., Wisnivesky, J. P., Cone, J. E., Friedman, S. M., & Brackbill, R. M. (2018). Hospitalizations for asthma among adults exposed to the September 11, 2001 World Trade Center terrorist attack. Journal of Asthma, 55(4), 354–363. https://doi.org/10.1080/02770903.2017.1337787 
  • Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks
    • 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.
    • Jordan, H. T., Friedman, S. M., Reibman, J., Goldring, R. M., Miller Archie, S. A., Ortega, F., Alper, H., Shao, Y., Maslow, C. B., Cone, J. E., Farfel, M. R., & Berger, K. I. (2017). Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks. Occupational and Environmental Medicine, 74(6), 449–455. https://doi.org/10.1136/oemed-2016-104157

2016

  • Determinants of asthma morbidity in World Trade Center rescue and recovery workers
    • The study found that many World Trade Center rescue and recovery workers had poorly controlled asthma for years after 9/11. Their asthma was worse when they also had other physical and mental health problems as well as lower incomes. Workers who developed asthma after 9/11 also had more serious symptoms than those with pre 9/11 asthma, which may be reflective of protective equipment or of the dangers associated with developing asthma later in life. These findings can help doctors identify workers at higher risk and create better treatments to improve their health and quality of life.
    • Xu, K. Y., Goodman, E., Goswami, R., Crane, M., Crowley, L., Busse, P., Katz, C. L., Markowitz, S., De La Hoz, R. E., Jordan, H. T., Skloot, G., & Wisnivesky, J. P. (2016). Determinants of asthma morbidity in World Trade Center rescue and recovery workers. Annals of Allergy, Asthma & Immunology, 117(5), 568–570. https://doi.org/10.1016/j.anai.2016.08.033
  • Asthma among Staten Island fresh kills landfill and barge workers following the September 11, 2001 World Trade Center terrorist attacks
    • 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.
    • Cone, J. E., Osahan, S., Ekenga, C. C., Miller‐Archie, S. A., Stellman, S. D., Fairclough, M., Friedman, S. M., & Farfel, M. R. (2016). Asthma among Staten Island fresh kills landfill and barge workers following the September 11, 2001 World Trade Center terrorist attacks. American Journal of Industrial Medicine, 59(9), 795–804. https://doi.org/10.1002/ajim.22645 
  • Risk factors for and consequences of persistent lower respiratory symptoms among World Trade Center Health Registrants 10 years after the disaster
    • 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: Persistent Cough, Wheezing, Shortness of Breath. 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.
    • Friedman, S. M., Farfel, M. R., Maslow, C., Jordan, H. T., Li, J., Alper, H., Cone, J. E., Stellman, S. D., & Brackbill, R. M. (2016). Risk factors for and consequences of persistent lower respiratory symptoms among World Trade Center Health Registrants 10 years after the disaster. Occupational and Environmental Medicine, 73(10), 676–684. https://doi.org/10.1136/oemed-2015-103512 

2015

  • Oscillometry complements spirometry in evaluation of subjects following toxic inhalation
    • A study of people exposed to the World Trade Center disaster found that standard lung tests often missed breathing problems. Researchers compared 848 people with breathing symptoms to 475 people without symptoms. Most had normal spirometry results, but a more sensitive test found signs of airway problems in people with symptoms. These airway changes were also worse in people with more severe wheezing. The findings suggest that small airway problems may explain some long-term breathing symptoms after 9/11.
    • Berger, K. I., Turetz, M., Liu, M., Shao, Y., Kazeros, A., Parsia, S., Caplan-Shaw, C., Friedman, S. M., Maslow, C. B., Marmor, M., Goldring, R. M., & Reibman, J. (2015). Oscillometry complements spirometry in evaluation of subjects following toxic inhalation. ERJ Open Research, 1(2), 00043–02015. https://doi.org/10.1183/23120541.00043-2015
  • Factors associated with poor control of 9/11-related asthma 10-11 years after the 2001 World Trade Center disaster
    • 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.
    • Jordan, H. T., Stellman, S. D., Reibman, J., Farfel, M. R., Brackbill, R. M., Friedman, S. M., Li, J., & Cone, J. E. (2015). Factors associated with poor control of 9/11-related asthma 10–11 years after the 2001 World Trade Center terrorist attacks. Journal of Asthma, 52(6), 630–637. https://doi.org/10.3109/02770903.2014.999083

2012

  • Chronic and acute exposures to the World Trade Center disaster and lower respiratory symptoms: area residents and workers
    • 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.
    • Maslow, C. B., Friedman, S. M., Pillai, P. S., Reibman, J., Berger, K. I., Goldring, R., Stellman, S. D., & Farfel, M. (2012). Chronic and Acute Exposures to the World Trade Center Disaster and Lower Respiratory Symptoms: Area Residents and Workers. American Journal of Public Health, 102(6), 1186–1194. https://doi.org/10.2105/AJPH.2011.300561 

2011

  • Respiratory protective equipment, mask use, and respiratory outcomes among World Trade Center rescue and recovery workers
    • A study of 9,296 World Trade Center rescue and recovery workers found that workers who used respirators were less likely to report long-term breathing problems than those who used little or no protection. Workers who received safety training were also more likely to use protective equipment correctly. The study shows that providing proper equipment and training can help protect emergency workers during disaster recovery efforts.
    • Antao, V. C., Pallos, L. L., Shim, Y. K., Sapp, J. H., Brackbill, R. M., Cone, J. E., Stellman, S. D., & Farfel, M. R. (2011). Respiratory protective equipment, mask use, and respiratory outcomes among World Trade Center rescue and recovery workers. American Journal of Industrial Medicine, 54(12), 897–905. https://doi.org/10.1002/ajim.21009 
  • Case-control study of lung function in World Trade Center Health Registry area residents and workers
    • A study of 653 residents and workers exposed to the World Trade Center disaster found that some people continued to have breathing problems 7–8 years after 9/11. Those with lasting symptoms were more likely to have abnormal lung tests, including signs of blocked airways. Some people had these problems even when standard lung tests were normal. The findings suggest that long-term exposure to dust and fumes may cause lasting changes in the lungs.
    • Friedman, S. M., Maslow, C. B., Reibman, J., Pillai, P. S., Goldring, R. M., Farfel, M. R., Stellman, S. D., & Berger, K. I. (2011). Case–Control Study of Lung Function in World Trade Center Health Registry Area Residents and Workers. American Journal of Respiratory and Critical Care Medicine, 184(5), 582–589. https://doi.org/10.1164/rccm.201011-1909OC 

2007

  • Asthma diagnosed after 11 September 2001 among rescue and recovery workers: findings from the World Trade Center Health Registry
    • A study of 25,748 World Trade Center rescue and recovery workers found that 3.6% developed asthma after the September 11 attacks. Workers who arrived at the site sooner, stayed longer, and faced more dust exposure had a higher risk of developing asthma. The study also found that using masks or respirators earlier helped lower this risk. These findings show the importance of providing protective equipment quickly during disaster response.
    • Wheeler, K., McKelvey, W., Thorpe, L., Perrin, M., Cone, J., Kass, D., Farfel, M., Thomas, P., & Brackbill, R. (2007). Asthma Diagnosed after 11 September 2001 among Rescue and Recovery Workers: Findings from the World Trade Center Health Registry. Environmental Health Perspectives, 115(11), 1584–1590. https://doi.org/10.1289/ehp.10248