Michael Crane

Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study.

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.

Cancer Incidence in World Trade Center Rescue and Recovery Workers, 2001–2008

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.

The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort

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.

Prevalence and predictors of posttraumatic stress symptoms in utility workers deployed to the world trade center following the attacks of September 11, 2001.

Background: Recent attention has begun to be focused on the effects of disaster recovery work on nonrescue workers. The goal of this study was to assess the prevalence and predictors of posttraumatic stress disorder (PTSD) and related symptoms in a population of utility workers deployed to the World Trade Center (WTC) site in the aftermath of 9/11. Methods: Utility workers deployed to the WTC site were screened at their place of employment between 10 and 34 months following the WTC attacks, utilizing both structured interviews and self‐report measures. PTSD symptoms were assessed by the CAPS and the PCL; co‐morbid disorders were also assessed. 2,960 individuals with complete CAPS and PCL data were included in the analyses. Results: Eight percent of participants had symptoms consistent with full PTSD, 9.3% with subthreshold PTSD, 6% with MDD, 3.5% with GAD, and 2.5% with panic disorder. Although risk factors included psychiatric and trauma history, 51% of individuals with probable PTSD had neither; subjective perception of threat to ones life was the best predictor of probable PTSD. Extent of exposure predicted 89% of PTSD cases in those without a psychiatric or trauma history, but only 67% of cases among those with both. Conclusions: Nonrescue workers deployed to a disaster site are at risk for PTSD and depression. Extent of exposure affected the most vulnerable workers differently than the least vulnerable ones. These results suggest that the relationship among predictors of PTSD may be different for different vulnerability groups, and underscore the importance of screening, education, and prevention programs for disaster workers. Depression and Anxiety 28:210–217, 2011.  © 2010 Wiley‐Liss, Inc.

The longitudinal course of PTSD among disaster workers deployed to the World Trade Center following the attacks of September 11th

This study examined the long-term mental health outcomes of 2,960 nonrescue disaster workers deployed to the World Trade Center site in New York City following the September 11, 2001 (9/11) terrorist attacks. Semistructured interviews and standardized self-report measures were used to assess the prevalence of posttraumatic stress disorder (PTSD) and other psychopathology 4 and 6 years after the attacks. Clinician-measured rates of PTSD and partial PTSD 4-years posttrauma were 8.4% and 8.9%, respectively, in a subsample of 727 individuals. Rates decreased to 5.8% and 7.7% for full and partial PTSD 6 years posttrauma. For the larger sample, self-report scores revealed probable PTSD and partial PTSD prevalence to be 4.8% and 3.6% at 4 years, and 2.4% and 1.8% at 6 years. Approximately 70% of workers never met criteria for PTSD. Although PTSD rates decreased significantly over time, many workers remained symptomatic, with others showing delayed-onset PTSD. The strongest predictors of ongoing PTSD 6 years following 9/11 were trauma history (odds ratio (OR) = 2.27, 95% confidence interval (CI) [1.06, 4.85]); the presence of major depressive disorder 1-2 years following the trauma (OR = 2.80, 95% CI [1.17, 6.71]); and extent of occupational exposure (OR = 1.31, 95% CI [1.13, 1.51]). The implications of the findings for both screening and treatment of disaster workers are discussed.

Reflux symptoms and disorders and pulmonary disease in former World Trade Center rescue and recovery workers and volunteers.

Background:Gastroesophageal reflux disease is one of the most prevalent conditions among former World Trade Center (WTC) rescue and recovery workers. The reason for this proposed association with an inhalation injury is unclear. In this study, we clinically characterized the reflux disorders in former WTC workers, and we investigated their association with pulmonary function abnormalities and with clinical diagnoses of other WTC-related diseases. Methods:Forty-two former WTC workers underwent the following testing: symptom inventories, physical examination, spirometry, esophagogastroduodenoscopy, and 24-hour pH monitoring studies for the evaluation of chronic reflux-like symptoms. Patients were classified into two groups based on clinical evaluation: group 1 (reflux patients) including definitive reflux disorders (gastroesophageal reflux, nonerosive reflux, nonacid reflux, and laryngopharyngeal reflux diseases) and group 2 (no-reflux patients) patients without clinically significant reflux disease, including functional heartburn, and hypersensitive esophagus disorder. Results:The reflux and no-reflux patients had significantly different Johnson-DeMeester scores and esophageal acid exposure times. Patients with reflux disorders were more likely to have reduced forced vital capacity (&khgr;2 = 5.49, P = 0.031) and also more likely to have been diagnosed with a lower airway disease (&khgr;2 = 7.14, P = 0.008). We found no significant association between reflux and psychiatric disorders (&khgr;2 = 0.02, P = 0.89), levels of exposure at the WTC site, or incidence of dry cough, or other upper airway disorders. Conclusions:A spectrum of reflux symptoms and disorders are present in WTC responders. Our data suggest that the presence of reflux disease is related to that of pulmonary function abnormality suggestive of air trapping and a diagnosis of a lower respiratory disease.

World Trade Center disaster and sensitization to subsequent life stress: A longitudinal study of disaster responders

PURPOSE The current study examined the role of World Trade Center (WTC) disaster exposure (hours spent working on the site, dust cloud exposure, and losing friend/loved one) in exacerbating the effects of post-disaster life stress on posttraumatic stress disorder (PTSD) symptoms and overall functioning among WTC responders. METHOD Participants were 18,896 responders (8466 police officers and 10,430 non-traditional responders) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and were reassessed an average of two years later. RESULTS Among police responders, there was a significant interaction, such that the effect of post-disaster life stress on later PTSD symptoms and overall functioning was stronger among police responders who had greater WTC disaster exposure (βs=.029 and .054, respectively, for PTSD symptoms and overall functioning). This moderating effect was absent in non-traditional responders. Across both groups, post-disaster life stress also consistently was related to the dependent variables in a more robust manner than WTC exposure. DISCUSSION The present findings suggest that WTC exposure may compound post-disaster life stress, thereby resulting in a more chronic course of PTSD symptoms and reduced functioning among police responders.

Destruction of the World Trade Center Towers. Lessons Learned from an Environmental Health Disaster.

The assault and subsequent collapse of the World Trade Center towers in New York City on September 11, 2001 (9/11), released more than a million tons of debris and dust into the surrounding area, engulfing rescue workers as they rushed to aid those who worked in the towers, and the thousands of nearby civilians and children who were forced to flee. In December 2015, almost 15 years after the attack, and 5 years after first enactment, Congress reauthorized the James Zadroga 9/11 Health and Compensation Act, a law designed to respond to the adverse health effects of the disaster. This reauthorization affords an opportunity to review human inhalation exposure science in relation to the World Trade Center collapse. In this Special Article, we compile observations regarding the collective medical response to the environmental health disaster with a focus on efforts to address the adverse health effects experienced by nearby community members including local residents and workers. We also analyze approaches to understanding the potential for health risk, characterization of hazardous materials, identification of populations at risk, and shortfalls in the medical response on behalf of the local community. Our overarching goal is to communicate lessons learned from the World Trade Center experience that may be applicable to communities affected by future environmental health disasters. The World Trade Center story demonstrates that communities lacking advocacy and preexisting health infrastructures are uniquely vulnerable to health disasters. Medical and public health personnel need to compensate for these vulnerabilities to mitigate long-term illness and suffering.

Post-disaster stressful life events and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among responders to the World Trade Center disaster.

BACKGROUND The current study examined contributions of post-disaster stressful life events in relation to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning among rescue, recovery, and clean-up workers who responded to the September 11, 2001 World Trade Center (WTC) terrorist attacks. METHODS Participants were 18,896 WTC responders, including 8466 police officers and 10,430 non-traditional responders (85.8% male; 86.4% Caucasian; M(age) = 39.5, SD = 8.8) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and who were reassessed, on average, 2.5 years later. RESULTS Path analyses were conducted to evaluate contributions of life events to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning. These analyses were stratified by police and non-traditional responder groups and adjusted for age, sex, time from 9/11 to initial visit, WTC exposures (three WTC contextual exposures: co-worker, friend, or a relative died in the disaster; co-worker, friend, or a relative injured in the disaster; and responder was exposed to the dust cloud on 9/11), and interval from initial to first follow-up visit. In both groups, WTC-related posttraumatic stress, depressive symptoms, and overall functioning were stable over the follow-up period. WTC exposures were related to these three outcomes at the initial assessment. WTC-related posttraumatic stress, depressive symptoms, and overall functioning, at the initial assessment each predicted the occurrence of post-disaster stressful life events, as measured by Disaster Supplement of the Diagnostic Interview Schedule. Post-disaster stressful life events, in turn, were associated with subsequent mental health, indicating partial mediation of the stability of observed mental health. CONCLUSIONS The present findings suggest a dynamic interplay between exposure, post-disaster stressful life events, and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among WTC disaster responders.

Risk, coping and PTSD symptom trajectories in World Trade Center 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.