Posttraumatic stress disorder (PTSD) is a debilitating and often chronic psychiatric disorder. Following the 9/11/2001 World Trade Center (WTC) attacks, thousands of individuals were involved in rescue, recovery and clean-up efforts. While a growing body of literature has documented the prevalence and correlates of PTSD in WTC responders, no study has evaluated predominant typologies of PTSD in this population. Participants were 4352 WTC responders with probable WTC-related DSM-IV PTSD. Latent class analyses were conducted to identify predominant typologies of PTSD symptoms and associated correlates. A 3-class solution provided the optimal representation of latent PTSD symptom typologies. The first class, labeled "High-Symptom (n = 1,973, 45.3%)," was characterized by high probabilities of all PTSD symptoms. The second class, "Dysphoric (n = 1,371, 31.5%)," exhibited relatively high probabilities of emotional numbing and dysphoric arousal (e.g., sleep disturbance). The third class, "Threat (n = 1,008, 23.2%)," was characterized by high probabilities of re-experiencing, avoidance and anxious arousal (e.g., hypervigilance). Compared to the Threat class, the Dysphoric class reported a greater number of life stressors after 9/11/2001 (OR = 1.06). The High-Symptom class was more likely than the Threat class to have a positive psychiatric history before 9/11/2001 (OR = 1.7) and reported a greater number of life stressors after 9/11/2001 (OR = 1.1). The High-Symptom class was more likely than the Dysphoric class, which was more likely than the Threat class, to screen positive for depression (83% > 74% > 53%, respectively), and to report greater functional impairment (High-Symptom > Dysphoric [Cohen d = 0.19], Dysphoric > Threat [Cohen d = 0.24]). These results may help inform assessment, risk stratification, and treatment approaches for PTSD in WTC and disaster responders.

Trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms are often heterogeneous, and associated with common and unique risk factors, yet little is known about potentially modifiable psychosocial characteristics associated with low-symptom and recovering trajectories in disaster responders. A total of 4487 rescue and recovery workers (1874 police and 2613 non-traditional responders) involved during and in the aftermath of the unprecedented World Trade Center (WTC) attacks, were assessed an average of 3, 6, 8, and 12 years post-9/11/2001. Among police responders, WTC-related PTSD symptoms were characterized by four trajectories, including no/low-symptom (76.1%), worsening (12.1%), improving (7.5%), and chronic (4.4%) trajectories. In non-traditional responders, a five-trajectory solution was optimal, with fewer responders in a no/low-symptom trajectory (55.5%), and the remainder in subtly worsening (19.3%), chronic (10.8%), improving (8.5%), and steeply worsening (5.9%) trajectories. Consistent factors associated with symptomatic PTSD trajectories across responder groups included Hispanic ethnicity, pre-9/11 psychiatric history, greater WTC exposure, greater medical illness burden, life stressors and post-9/11 traumas, and maladaptive coping (e.g., substance use, avoidance coping). Higher perceived preparedness, greater sense of purpose in life, and positive emotion-focused coping (e.g., positive reframing, acceptance) were negatively associated with symptomatic trajectories. Findings in this unique cohort indicate considerable heterogeneity in WTC-related PTSD symptom trajectories over 12 years post-9/11/2001, with lower rates of elevated PTSD symptoms in police than in non-traditional responders. They further provide a comprehensive risk prediction model of PTSD symptom trajectories, which can inform prevention, monitoring, and treatment efforts in WTC and other disaster responders.

Background: World Trade Center (WTC) rescue and recovery workers were exposed to a complex mix of pollutants and carcinogens.Objective: The purpose of this investigation was to evaluate cancer incidence in responders during the first 7 years after 11 September 2001.Methods: Cancers among 20,984 consented participants in the WTC Health Program were identified through linkage to state tumor registries in New York, New Jersey, Connecticut, and Pennsylvania. Standardized incidence ratios (SIRs) were calculated to compare cancers diagnosed in responders to predicted numbers for the general population. Multivariate regression models were used to estimate associations with degree of exposure.Results: A total of 575 cancers were diagnosed in 552 individuals. Increases above registry-based expectations were noted for all cancer sites combined (SIR = 1.15; 95% CI: 1.06, 1.25), thyroid cancer (SIR = 2.39; 95% CI: 1.70, 3.27), prostate cancer (SIR = 1.21; 95% CI: 1.01, 1.44), combined hematopoietic and lymphoid cancers (SIR = 1.36; 95% CI: 1.07, 1.71), and soft tissue cancers (SIR = 2.26; 95% CI: 1.13, 4.05). When restricted to 302 cancers diagnosed ≥ 6 months after enrollment, the SIR for all cancers decreased to 1.06 (95% CI: 0.94, 1.18), but thyroid and prostate cancer diagnoses remained greater than expected. All cancers combined were increased in very highly exposed responders and among those exposed to significant amounts of dust, compared with responders who reported lower levels of exposure.Conclusion: Estimates should be interpreted with caution given the short follow-up and long latency period for most cancers, the intensive medical surveillance of this cohort, and the small numbers of cancers at specific sites. However, our findings highlight the need for continued follow-up and surveillance of WTC responders.

BACKGROUND:This study examined the prevalence, correlates, and perceived mental healthcare needs associated with subsyndromal PTSD in police involved in the World Trade Center (WTC) rescue and recovery effort. METHODS:A total of 8466 police completed an interview/survey as part of the WTC Medical monitoring and Treatment Program an average of four years after 9/11/2001. RESULTS:The past month prevalence of full and subsyndromal WTC-related PTSD was 5.4% and 15.4%, respectively. Loss of someone or knowing someone injured on 9/11 (odds ratios [ORs]=1.56-1.86), pre-9/11 stressors (ORs=1.30-1.50), family support (ORs=0.83-0.94), and union membership (ORs=0.50-0.52) were associated with both full and subsyndromal PTSD. Exposure to the dust cloud (OR=1.36), performing search and rescue work (OR=1.29), and work support (OR=0.89) were additionally associated with subsyndromal PTSD. Rates of comorbid depression, panic disorder, and alcohol use problems (ORs=3.82-41.74), and somatic symptoms and functional difficulties (ORs=1.30-1.95) were highest among police with full PTSD, with intermediate rates among police with subsyndromal PTSD (ORs=2.93-7.02; and ORs=1.18-1.60, respectively). Police with full and subsyndromal PTSD were significantly more likely than controls to report needing mental healthcare (41.1% and 19.8%, respectively, versus 6.8% in trauma controls). CONCLUSIONS:These results underscore the importance of a more inclusive and dimensional conceptualization of PTSD, particularly in professions such as police, as operational definitions and conventional screening cut-points may underestimate the psychological burden for this population. Accordingly, psychiatric clinicians should assess for disaster-related subsyndromal PTSD symptoms in disaster response personnel.

Introduction: In 2002, the Mount Sinai Center for Occupational and Environmental Medicine, with support from the National Institute for Occupational Safety and Health (NIOSH), began coordinating the World Trade Center (WTC) Worker and Volunteer Medical Screening Program (MSP) to monitor the health of qualified WTC responders. Enrolled participants were offered a clinical examination; interviewed to collect medical, mental health, and exposure information; and requested to complete a self-administered medical questionnaire. The objective of this study was to better understand work-related injuries and illnesses sustained on-site by WTC responders.Methods: A descriptive analysis of select data from the MSP self-administered medical questionnaire was conducted. Data collected July 2002 through April 2004 from MSP participants enrolled at the Mount Sinai clinic were reviewed using univariate statistical techniques.Results: Records from 7,810 participants were analyzed, with most participants associated with either the construction industry (n = 2,623, 34%) or law enforcement (n = 2,036, 26%). Approximately a third of the participants (n = 2,486, 32%) reported at least one injury or illness requiring medical treatment that was sustained during WTC work/volunteer activities. Of the total 4,768 injuries/illnesses reported by these participants, respiratory complaints were most common (n = 1,350, 28%), followed by traumatic injuries excluding eye injuries (n = 961, 20%), eye injuries/ailments (n = 709, 15%), chest pain (n = 375, 8%), headaches (n = 359, 8%), skin conditions (n = 178, 4%), and digestive system conditions (n = 163, 3%). Participants reported that 36% of injuries/illnesses were treated off-site and 29% were treated on-site, with the remaining not specifying treatment location. Off-site treatment was prevalent for respiratory complaints, psychological stress, and chest pain. On-site treatment was predominate for eye injuries/ailments and traumatic injuries excluding eye injuries.Conclusion: Study results underscore the need for rapid deployment of personal protective equipment for disaster responders and medical care stations mobilized near disaster worksites. Additionally, the results, many of which are comparable to findings from previous WTC studies where data were collected in real-time, indicate that a screening program such as the MSP may be effective in retrospectively providing general information on disaster responder demographics and work-related injuries and illnesses.

BACKGROUND:More than 50,000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities. METHODS:In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27,449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud). FINDINGS:9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders. INTERPRETATION:9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population. FUNDING:Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health.

BACKGROUND:Studies have documented high rates of asthma symptoms among responders to the World Trade Center (WTC) disaster. However, whether there are increased rates of asthma among responders compared to the general population is unknown.METHODS:The study population consisted of a prospective cohort of 20,834 responders participating in the WTC Medical Monitoring and Treatment Program between July 2002 and December 2007. We calculated prevalence and standardized morbidity ratios (SMRs) of lifetime asthma and 12-month asthma (defined as ≥1 attacks in the prior 12 months) among WTC responders. The comparison population consisted of >200,000 adults who completed the National Health Interview Survey in 2000 (for pre-9/11 comparisons) and between 2002 and 2007 (for post-9/11 comparisons).RESULTS:WTC responders were on average 43 ± 9 years old, 86% male, 59% white, and 42% had an occupation in protective services. The lifetime prevalence of asthma in the general population was relatively constant at about 10% from 2000 to 2007. However, among WTC responders, lifetime prevalence increased from 3% in 2000, to 13% in 2002, and 19% in 2007. The age-adjusted overall SMR for lifetime asthma among WTC responders was 1.8 (95% CI: 1.8-1.9) for men and 2.0 (95% CI: 1.9-2.1) for women. Twelve-month asthma was also more frequent among WTC responders compared to the general population (SMR 2.4, 95% CI: 2.2-2.5) for men and 2.2 (95% CI: 2.0-2.5) for women.CONCLUSIONS:WTC responders are at an increased risk of asthma as measured by lifetime prevalence or active disease.

BACKGROUND:To date there have been no comprehensive reports of the work performedby 9/11 World Trade Center responders.METHODS:18,969 responders enrolled in the WTC Medical Monitoring and Treatment Program were used to describe workers’ pre-9/11 occupations, WTC work activities and locations from September 11, 2001 to June 2002.RESULTS:The most common pre-9/11 occupation was protective services (47%); other common occupations included construction, telecommunications, transportation, and support services workers. 14% served as volunteers. Almost one-half began work on 9/11 and >80% reported working on or adjacent to the ‘‘pile’’ at Ground Zero. Initially,the most common activity was search and rescue but subsequently, the activities of most responders related to their pre-9/11 occupations. Other major activities included security; personnel support; buildings and grounds cleaning; and telecommunications repair.CONCLUSIONS:The spatial, temporal, occupational, and task-related taxonomy reported here will aid the development of a job-exposure matrix, assist in assessment of disease risk, and improve planning and training for responders in future urban disasters.

Following the World Trade Center (WTC) collapse on September 11, 2001, more than 40,000 people were exposed to a complex mixture of inhalable nanoparticles and toxic chemicals. While many developed chronic respiratory symptoms, to what degree olfaction was compromised is unclear. A previous WTC Medical Monitoring and Treatment Program study found that olfactory and nasal trigeminal thresholds were altered by the toxic exposure, but not scores on a 20-odor smell identification test.To employ a well-validated 40-item smell identification test to definitively establish whether the ability to identify odors is compromised in a cohort of WTC-exposed individuals and, if so, whether the degree of compromise is associated with self-reported severity of rhinitic symptoms.The University of Pennsylvania Smell Identification Test (UPSIT) was administered to 99 WTC-exposed persons and 99 matched normal controls. The Sino-Nasal Outcomes Test (SNOT-20) was administered to the 99 WTC-exposed persons and compared to the UPSIT scores.The mean (SD) UPSIT scores were lower in the WTC-exposed group than in age-, sex-, and smoking history-matched controls [respective scores: 30.05 (5.08) vs 35.94 (3.76); p = 0.003], an effect present in a subgroup of 19 subjects additionally matched on occupation (p < 0.001). Fifteen percent of the exposed subjects had severe microsmia, but only 3% anosmia. SNOT-20 scores were unrelated to UPSIT scores (r = 0.20; p = 0.11).Exposure to WTC air pollution was associated with a decrement in the ability to identify odors, implying that such exposure had a greater influence on smell function than previously realized.

OBJECTIVE:To determine the ability of spirometry technicians in the World Trade Center Worker and Volunteer Medical Screening Program to meet American Thoracic Society spirometry quality goals.METHODS:Spirometry technicians were trained centrally and performed spirometry sessions at 6 sites in the greater New York City area. We reviewed and graded the spirometry results for quality every month.RESULTS:About 80% (range 70-88%) of the spirometry sessions met the American Thoracic Society spirometry goals. In general, the spirometry technicians with the most experience were more successful in meeting the quality goals. Participant characteristics explained very little of the quality variability.CONCLUSIONS:The overall spirometry quality in this multicenter program was very good. Efforts to improve spirometry quality should focus on the performance of individual spirometry technicians.

CONTEXT:After the collapse of the World Trade Center (WTC) on 11 September 2001, a dense cloud of dust containing high levels of airborne pollutants covered Manhattan and parts of Brooklyn, New York. Between 60,000 and 70,000 responders were exposed. Many reported adverse health effects.CASE PRESENTATION:In this report we describe clinical, pathologic, and mineralogic findings in seven previously healthy responders who were exposed to WTC dust on either 11 September or 12 September 2001, who developed severe respiratory impairment or unexplained radiologic findings and underwent video-assisted thoracoscopic surgical lung biopsy procedures at Mount Sinai Medical Center. WTC dust samples were also examined. We found that three of the seven responders had severe or moderate restrictive disease clinically. Histopathology showed interstitial lung disease consistent with small airways disease, bronchiolocentric parenchymal disease, and nonnecrotizing granulomatous condition. Tissue mineralogic analyses showed variable amounts of sheets of aluminum and magnesium silicates, chrysotile asbestos, calcium phosphate, and calcium sulfate. Small shards of glass containing mostly silica and magnesium were also found. Carbon nanotubes (CNT) of various sizes and lengths were noted. CNT were also identified in four of seven WTC dust samples.DISCUSSION:These findings confirm the previously reported association between WTC dust exposure and bronchiolar and interstitial lung disease. Long-term monitoring of responders will be needed to elucidate the full extent of this problem. The finding of CNT in both WTC dust and lung tissues is unexpected and requires further study.

BACKGROUND More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of "sarcoid like" granulomatous pulmonary disease in other WTC responders. METHODS Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only "definite" cases are reported. RESULTS Thirty-eight patients were classified as "definite" cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality. CONCLUSIONS Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected.

BACKGROUND: Individuals involved in rescue, recovery, demolition, and cleanup at the World Trade Center (WTC) site were exposed to a complex mixture of airborne smoke, dust, combustion gases, acid mists, and metal fumes. Such exposures have the potential to impair nasal chemosensory (olfactory and trigeminal) function.OBJECTIVE: The goal of this study was to evaluate the prevalence of chemosensory dysfunction and nasal inflammation among these individuals.METHODS: We studied 102 individuals who worked or volunteered at the WTC site in the days and weeks during and after 11 September 2001 (9/11) and a comparison group with no WTC exposure matched to each participant on age, sex, and job title. Participants were comprehensively evaluated for chemosensory function and nasal inflammation in a single session. Individual exposure history was obtained from self-reported questionnaires.RESULTS: The prevalence of olfactory and trigeminal nerve sensitivity loss was significantly greater in the WTC-exposed group relative to the comparison group [prevalence ratios (95% confidence intervals) = 1.96 (1.2-3.3) and 3.28 (2.7-3.9) for odor and irritation thresholds, respectively]. Among the WTC responders, however, individuals caught in the dust cloud from the collapse on 9/11 exhibited the most profound trigeminal loss. Analysis of the nasal lavage samples supported the clinical findings of chronic nasal inflammation among the WTC-exposed cohort.CONCLUSIONS: The prevalence of significant chemosensory impairment in the WTC-exposed group more than 2 years after their exposure raises concerns for these individuals when the ability to detect airborne odors or irritants is a critical safety factor.RELEVANCE TO CLINICAL PRACTICE: This outcome highlights the need for chemosensory evaluations among individuals with exposure to acute high or chronic levels of airborne pollutants.

BACKGROUND:Snoring is a common symptom among workers with adverse health effects from their World Trade Center (WTC) occupational exposures. Rhinitis and upper airway disease are highly prevalent among these workers. Rhinitis has been associated with snoring and, in some studies, with obstructive sleep apnea (OSA). We examined the association of WTC exposure and findings on nocturnal polysomnogram, as well as known predictors of OSA in this patient population.METHODS:One hundred participants with snoring underwent a polysomnogram to exclude OSA. Comorbidities had been previously evaluated and treated. The apnea-hypopnea index (AHI) defined and categorized the severity of OSA. Age, sex, body mass index (BMI), and WTC exposure variables were examined in bivariate and multiple regression analyses.RESULTS:Our study sample had a similar prevalence of five major disease categories, as we previously reported. OSA was diagnosed in 62% of the patients and was not associated with any of those disease categories. A trend toward increasing AHI with increasing WTC exposure duration failed to reach the statistical significance (P = 0.14) in multiple regression analysis. An elevated AHI was associated with BMI (P = 0.003) and male sex (P < 0.001).CONCLUSIONS:OSA was associated with BMI and male sex but not with occupational WTC exposure indicators in this patient population.

We first consider a wildlife-related capture recapture problem with a known total number of fish. Our objective is to estimate the number of healthy fish, H. We first use a rod that only attracts healthy fish, which are tagged and returned to the water. Later, we use a net that scoops both sick and healthy fish. Three assumptions regarding the probability of being caught by the net, conditional on health status and being caught by the rod, lead to three different estimates of H. We give approximations to expected values of the three estimates and give a condition under which they bracket H. A potential application of these methods is to the follow-up of World Trade Center responders. Responders are disease-free when they arrive at the clean-up site and are asked to report for a visit after a fixed period of time, but some fail to do so. Some responders, whether they come to the scheduled return visit or not, spontaneously report a disease before the scheduled visit, but absence of disease is never reported in this manner. We use the methods developed to estimate the total number of subjects with disease by the time of the scheduled return visit.

PURPOSE: We compared the prevalence of asthma among WTC responders to the general population of adults in the United States.

A qualitative study of the experiences of rescue and recovery workers/volunteers at Ground Zero following the terrorist attacks of 9/11/01 is reported. Information was extracted from a semi-structured clinical evaluation of 416 responders who were the initial participants in a large scale medical and mental health screening and treatment program for 9/11 responders. Qualitative analysis revealed themes that spanned four categories- occupational roles, exposures, attitudes/experiences, and outcomes related to the experience of Ground Zero. Themes included details regarding Ground Zero roles, grotesque experiences such as smells, the sense of the surreal nature of responding, and a turning to rituals to cope after leaving Ground Zero. These findings personalize the symptom reports and diagnoses that have resulted from the 9/11 responders' exposure to Ground Zero, yielding richer information than would otherwise be available for addressing the psychological dimensions of disasters. This work shows that large scale qualitative surveillance of trauma-exposed populations is both relevant and feasible.

OBJECTIVE:A large number of workers seemed to have developed upper and lower airway disease (UAD and LAD, respectively) in relation to their occupational exposures at the World Trade Center (WTC) disaster site. This study examined atopy as a risk factor for presumably WTC-related UAD and LAD. METHODS:Atopy was examined in 136 former WTC workers and volunteers by radioallergosorbent test, skin prick testing, or both. Overall prevalence of atopy was estimated, and bivariate and multivariate logistic regression analyses were conducted to examine associations of atopy with WTC-related UAD and LAD. RESULTS:Atopy was prevalent in 54.4% of these WTC workers. Atopy was associated with higher symptom severity scores for both WTC-related UAD and LAD. Atopy was a predictor of WTC-related UAD but not LAD. Early arrival at the WTC site, and pre-2001 asthma diagnosis were predictors of LAD. CONCLUSION:The prevalence of atopy in this population is similar to what has been described for the general U.S. population. Atopy seemed to be a risk factor for presumably WTC-related UAD but not for LAD.

OBJECTIVES:We report on cases of multiple myeloma (MM) observed in World Trade Center (WTC) responders registered in the WTC Medical Program.METHODS:Possible cases of MM diagnosed between September 11, 2001, and September 10, 2007, in responders were confirmed if they met the World Health Organization and Mayo Clinic diagnostic criteria.RESULTS:Among 28,252 responders of known sex and age, eight cases of MM were observed (6.8 expected). Four of these cases were observed in responders younger than 45 years at the time of diagnosis (1.2 expected). A slight deficit of MM cases was observed in responders older than 45 years (4 observed, 5.6 expected).CONCLUSION:In this case series, we observe an unusual number of MM cases in WTC responders under 45 years. This finding underscores the importance of maintaining surveillance for cancer and other emerging diseases in this highly exposed population.