Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medical Screening Progra

1. Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medical Screening Program Robin Herbert M.D. World Trade Center Worker and Volunteer Medical Screening Program Mount Sinai School of Medicine

8. Initial Human Health Concerns • Upper airway inflammation • Rhinitis/sinusitis • Pharyngitis • Laryngitis/tracheitis • Reactive upper airway dysfunction • Bronchitis • Reactive airway disease (RADS)/ Asthma

9. Initial Human Health Concerns • Musculoskeletal injuries • Unstable, hazardous physical environment • Debris overlying voids • Dust suppression wets dusted surfaces • Concern about acute injury, with longer-term musculoskeletal sequelae • Actual acute trauma rate remarkably low

10. Initial Human Health Concerns • Psychological effects • PTSD • Anxiety • Depression • Social and economic consequences • Loss of employment due to physical and/or mental health conditions, economy • Impact on family functioning • Increase in substance/ETOH use

11. WTC Worker and Volunteer Medical Screening Program • Funded by NIOSH to rapidly establish a clinical program to provide 12,000 free standardized screening exams to WTC responders (NYC, NY/NJ, nationally) • Examination purposes: • To identify current WTC-related physical and mental health problems • To serve as baseline for future exams • To provide meaningful aggregate data in absence of control groups

12. Medical Screening Components • Self and interviewer-administered medical questionnaires • Physician-administered examination • Interviewer-administered exposure assessment questionnaire • Spirometry with bronchodilator • Chest x-ray • Routine blood work • Psychological screening and evaluation

13. Clinical Centers • Mount Sinai Center for Occupational and Environmental Clinic • Bellevue/NYU Occupational and Environmental Clinic • SUNY Stony Brook/Long Island Occupational and Environmental Health Center (Nassau and Suffolk counties) • Queens College Center for the Biology and of Natural Systems • UMDNJ Environmental and Occupational Health Services Institute (Piscataway, NJ) • 35 Association of Occupational and Environmental Clinics across the country, 2 independent clinical sites in Ca. and 1 independent clinical site in Florida

14. Between July 16, 2002 and July 14,2004, 11,768 WTC Responders were examined • Construction (2800+) • Law enforcement (1800+) • Technical and Utilities (600+) • Public sector- blue collar (500+) • Transportation (300+) • Cleaning/Maintenance (200+) • Ironworkers (200+)

15. MMWR Report: Reported on health of 1138 WTC responders seen at Mount Sinai between 7/16/02 and 12/31/02

16. Eligibility criteria (12/31/02) • Minimum of 24 hours working/volunteering during September 11-30, 2001 • Or • >80 hours during September 11-November 30,2001 • Either south of Canal Street, the Staten Island landfill, or barge loading piers • Employees of the Office of the Chief Medical Examiner • FDNY and State of New York employees had access to other screening programs and were not eligible

17. Demographics (n=1138)

18. Initial Arrival at WTC site • Exposure: • 525 (46%) worked on WTC rescue and recovery efforts on 9/11/01. • 963 (84%) worked or volunteered during 9/11/01 – 9/14/01 • 239 (21%) reported using appropriate respiratory protection through 9/14/01 • Median length of time worked on the WTC efforts was 966 hours (range: 24 – 4080 hours).

19. Pulmonary Symptoms (n=1138) • 682 (60%) reported at least one WTC-related pulmonary symptom (dry cough, chest tightness, shortness of breath, wheezing, awakened by shortness of breath). • 479 (42%) were still experiencing at least one WTC-related pulmonary symptom in the month before the screening examination.

20. Self-reported Lower Respiratory Symptoms:

21. Self-reported Lower Respiratory Symptoms:

22. Self-reported Lower Respiratory Symptoms:Previous History and Worsened 1 A small proportion of participants (n=2-19) are missing data on this question, except for “chest tightness,” n=164 missing

23. Self-reported Lower Respiratory Symptoms:Incidence (new onset) and Persistent 1 Based on a denominator of 1138

24. Upper Airway Symptoms (n=1138) • 836 (74%) reported at least one WTC-related ENT symptom while at the WTC site (throat irritation, blowing nose more than usual, head or sinus congestion, postnasal discharge, and/or nasal irritation). • 643 (57%) were still experiencing at least one ENT symptom in the month before the screening examination.

25. Self-reported Upper Respiratory Symptoms: 7 most prevalent symptoms

26. Self-reported Upper Respiratory Symptoms: 7 most prevalent symptoms

27. Self-reported Upper Respiratory Symptoms:Previous History and Worsened 1 A small proportion of participants (=2-19) are missing data on this question, except for “chest tightness,” n=164 missing 2 All are “excluding colds,” except “facial pain or pressure”

28. Self-reported Upper Respiratory Symptoms:Previous History and Worsened (cont.) 1 A small proportion of participants (=2-19) are missing data on this question, except for “chest tightness,” n=164 missing 2 All are “excluding colds,” except “facial pain or pressure”

29. Self-reported Upper Respiratory Symptoms:Incident (new onset) and Persistent 1 All are “excluding colds,” except “facial pain or pressure” 2 Based on a denominator of 1138

30. Self-reported Upper Respiratory Symptoms:Incident (new onset) and Persistent (cont.) 1 All are “excluding colds,” except “facial pain or pressure” 2 Based on a denominator of 1138

31. Self-reported Other Symptoms: 5 most prevalent symptoms

32. Self-reported Other Symptoms: 5 most prevalent symptoms

33. Self-reported Other Symptoms: Previous history and Worsened 1 A small proportion of participants (n=4-20) is missing data on specific questions

34. Self-reported Other Symptoms: Incidence (new onset) and Persistent

35. Comparison of 1138 Subgroup to Federal Employees Working Near the WTC Site

36. Pulmonary Function Tests • Pulmonary function tests demonstrated a high prevalence of respiratory abnormalities. • 360 (32%) had restriction, obstruction, or mixed abnormalities. • High prevalence of PFT abnormalities not likely to be due to smoking – 55% of sample never smoked.

37. Spirometry Results Footnotes: Includes the 1,085 participants with 3 good spirometry maneuvers and valid smoking status responses LLN = lower limit of the normal range, per Hankinson et al. 1999 Obstruction = FEV1/FVC < LLN and FVC > LLN (pre-bronchodilator) Restriction = FVC < LLN and FEV1/FVC > LLN Obstruction and low FVC = FEV1/FVC < LLN and FVC < LLN * BD (bronchodilator) response was defined as an increase of > 12% and > 0.2L in either FVC or FEV1 after inhaling albuterol ** Includes 75 participants with a normal FVC after bronchodilator (pseudo-restriction)

38. Comparison of Spirometry Results to “Never Smokers” in the General Population* using NHANES III data *Sample of employed, adult, white males

39. Mental Health Screening Questionnaire Results by Category * If exceeds threshold on General Health Questionnaire (GHQ), PCL, Patient Health Questionnaire (PHQ), or Life Impact Survey † If suicidal ideation was indicated on GHQ or PHQ.

40. Possible reason(s) for referral .

41. Main Conclusions • Primarily technical/utilities (25%), law enforcement (21%), construction (18%) • 46% worked on WTC-related efforts on 9/11/01 and 84% 9/11-9/14; BUT only 21% used respiratory protection during that time • 60% had WTC-related LA (new/worsened) while at WTC • 74% had WTC-related UA (new/worsened) while at WTC • 40% had incident WTC-related persistent LA to one month prior to screening • 50% had incident WTC-related persistent UA to one month prior to screening

42. Main Conclusions (cont.) • Fully 851 (75%) had at least one persistent WTC symptom • Among those 851 (75%) with any persistent symptom, an average of 32 weeks elapsed since they stopped working at WTC site or since close of site • PFTs- 33% abnormal • Among 599 non-smokers, 31% abnormal vs. 13% compared with NHANES III

43. Limitations • No reliable statistics exist on the size or composition of the exposed worker/volunteer population • Determining participation rates for screening program not possible • Screened population might over represent those most affected • Those examined earlier might not be representative of all persons screened • Persons examined earlier might have had more severe health problems and sought out program for that reason • Ability to measure accurately the impact of WTC exposures on responders’ is limited because of absence of pre-9/11 symptom prevalence and pulmonary function tests for these participants

44. Discussion:WTC Health Effects • WTC related symptoms have predominantly involved the upper and lower respiratory tracts and/or responders’ mental health • WTC related physical and mental health symptoms have been surprisingly persistent • Pattern of upper and lower respiratory and mental health symptoms is similar to that seen seen among NYFD and office workers from WTC vicinity

45. Discussion:WTC Health Effects • Many with persistent symptoms have received either no clinical care or inappropriate medical evaluation and/or treatment • Linkage of mental health component to physical health evaluation has been very successful

46. Discussion: unmet public health needs • Access to follow up medical and mental health care has been difficult: • For WTC-related problems: workers compensation delays, few occupational medicine specialists • For WTC-related mental health problems: few psychiatrists or other mental health providers are familiar with WC, need for Polish/Spanish speaking MH experts • For other medical problems: medically indigent

47. Discussion:challenges in primary prevention of WTC health effects • Many of the responders either did not have or did not use adequate respiratory protection in the immediate aftermath of the disaster • Many of the types of workers who responded did not work in occupations or industries where they were prepared to respond to acts of terrorism • Some occupational groups involved in the response were vulnerable workers such as non-English-speaking immigrants (e.g., day laborers/cleaners) who may have had less access to respiratory protection and health and safety training

48. Discussion: What is the significance of this for residents and workers in the WTC area? • Residents and workers from area surrounding WTC-site certainly also sustained exposure to both air contaminants and psychological traumatogens • Health burden not yet adequately evaluated

49. Acknowledgements • The entire staff of the World Trade Center Worker and Volunteer Medical Screening Program • Bellevue/NYU Occupational & Environmental Medicine Clinic • Center for the Biology of Natural Systems at Queens College • SUNY Stony Brook/Long Island Occupational and Environmental Health Clinic • Environmental & Occupational Health Sciences Institute at UMDNJ-Robert Wood Johnson Medical School/New Jersey • The Association of Occupational and Environmental Clinics • NIOSH/CDC • OUR WTC-RESPONDER PATIENTS!!!!!