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Title: Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medi


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

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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
  • gt80 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 (n1138)
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 (n1138)
  • 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
SymptomsPrevious History and Worsened
1 A small proportion of participants (n2-19) are
missing data on this question, except for chest
tightness, n164 missing
23
Self-reported Lower Respiratory
SymptomsIncidence (new onset) and Persistent
1 Based on a denominator of 1138
24
Upper Airway Symptoms (n1138)
  • 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, n164 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, n164 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 (n4-20) 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 lt LLN and FVC gt LLN (pre-bronchodilator)
Restriction FVC lt LLN and FEV1/FVC gt
LLN Obstruction and low FVC FEV1/FVC lt LLN and
FVC lt LLN BD (bronchodilator) response was
defined as an increase of gt 12 and gt 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
DiscussionWTC 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
DiscussionWTC 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
Discussionchallenges 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!!!!!
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