Title: Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medi
1Health 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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8Initial Human Health Concerns
- Upper airway inflammation
- Rhinitis/sinusitis
- Pharyngitis
- Laryngitis/tracheitis
- Reactive upper airway dysfunction
- Bronchitis
- Reactive airway disease (RADS)/ Asthma
9Initial 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
10Initial 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
11WTC 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
12Medical 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
14Between 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)
15MMWR Report
- Reported on health of 1138 WTC responders seen at
Mount Sinai between 7/16/02 and 12/31/02
16Eligibility 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
17Demographics (n1138)
18Initial 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).
19Pulmonary 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.
20Self-reported Lower Respiratory Symptoms
21Self-reported Lower Respiratory Symptoms
22Self-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
23Self-reported Lower Respiratory
SymptomsIncidence (new onset) and Persistent
1 Based on a denominator of 1138
24Upper 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.
25Self-reported Upper Respiratory Symptoms 7 most
prevalent symptoms
26Self-reported Upper Respiratory Symptoms 7 most
prevalent symptoms
27Self-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
28Self-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
29Self-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
30Self-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
31Self-reported Other Symptoms 5 most prevalent
symptoms
32Self-reported Other Symptoms 5 most prevalent
symptoms
33Self-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
35Comparison of 1138 Subgroup to Federal Employees
Working Near the WTC Site
36Pulmonary 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.
37Spirometry 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)
38Comparison of Spirometry Results to Never
Smokers in the General Population using NHANES
III data
Sample of employed, adult, white males
39Mental 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.
40Possible reason(s) for referral
.
41Main 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
42Main 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
43Limitations
- 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
44DiscussionWTC 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
45DiscussionWTC 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
46Discussion 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
47Discussionchallenges 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
48Discussion 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
49Acknowledgements
- 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!!!!!