A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers.

INTRODUCTION: Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up. MATERIALS AND METHODS: We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk. RESULTS: There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members. CONCLUSIONS: We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

Cancer incidence in World Trade Center rescue and recovery workers by race and ethnicity.

INTRODUCTION: It is unclear whether differences in health outcomes by racial and ethnic groups among World Trade Center (WTC) rescue and recovery workers reflect those of the population of New York State (NYS) or show distinct patterns. We assessed cancer incidence in WTC workers by self-reported race and ethnicity, and compared it to population figures for NYS. METHODS: A total of 61,031 WTC workers enrolled between September 11, 2001 and January 10, 2012 were followed to December 31, 2015. To evaluate the association between race/ethnicity and cancer risk, Poisson regression analysis was used to estimate hazard ratios (HR) adjusted for WTC exposure, age, calendar year, sex and, for lung cancer, cigarette smoking. RESULTS: In comparison to Whites, Black workers had a higher incidence of prostate cancer (HR = 1.99, 95% CI = 1.69-2.34) and multiple myeloma (HR = 3.57, 95% CI = 1.97-6.45), and a lower incidence of thyroid (HR = 0.41, 95% CI = 0.22-0.78) and colorectal cancer (HR = 0.57; 95% CI = 0.33-0.98). Hispanic workers had a higher incidence of liver cancer (HR = 4.03, 95% CI = 2.23-7.28). Compared with NYS population, White workers had significantly higher incidence of prostate cancer (HR = 1.26, 95% CI = 1.18-1.35) and thyroid cancer (HR = 1.80, 95% CI = 1.55-2.08), while Black workers had significantly higher incidence of prostate cancer (HR = 1.22, 95% CI = 1.05-1.40). CONCLUSION: Cancer incidence in WTC workers generally reflects data from the NYS population, but some differences were identified that merit further investigation.

Temporal association of prostate cancer incidence with World Trade Center rescue/recovery work.

BACKGROUND: The World Trade Center (WTC) attacks on 11 September 2001 created a hazardous environment with known and suspected carcinogens. Previous studies have identified an increased risk of prostate cancer in responder cohorts compared with the general male population. OBJECTIVES: To estimate the length of time to prostate cancer among WTC rescue/recovery workers by determining specific time periods during which the risk was significantly elevated. METHODS: Person-time accruals began 6 months after enrolment into a WTC cohort and ended at death or 12/31/2015. Cancer data were obtained through linkages with 13 state cancer registries. New York State was the comparison population. We used Poisson regression to estimate hazard ratios and 95% CIs; change points in rate ratios were estimated using profile likelihood. RESULTS: The analytic cohort included 54 394 male rescue/recovery workers. We observed 1120 incident prostate cancer cases. During 2002-2006, no association with WTC exposure was detected. Beginning in 2007, a 24% increased risk (HR: 1.24, 95% CI 1.16 to 1.32) was observed among WTC rescue/recovery workers when compared with New York State. Comparing those who arrived earliest at the disaster site on the morning of 11 September 2001 or any time on 12 September 2001 to those who first arrived later, we observed a positive, monotonic, dose-response association in the early (2002-2006) and late (2007-2015) periods. CONCLUSIONS: Risk of prostate cancer was significantly elevated beginning in 2007 in the WTC combined rescue/recovery cohort. While unique exposures at the disaster site might have contributed to the observed effect, screening practices including routine prostate specific antigen screening cannot be discounted.

Cancer survival among World Trade Center rescue and recovery workers: A collaborative cohort study.

BACKGROUND: World Trade Center (WTC)-exposed responders may be eligible to receive no-cost medical monitoring and treatment for certified conditions, including cancer. The survival of responders with cancer has not previously been investigated. METHODS: This study compared the estimated relative survival of WTC-exposed responders who developed cancer while enrolled in two WTC medical monitoring and treatment programs in New York City (WTC-MMTP responders) and WTC-exposed responders not enrolled (WTC-non-MMTP responders) to non-responders from New York State (NYS-non-responders), all restricted to the 11-southernmost NYS counties, where most responders resided. Parametric survival models estimated cancer-specific and all-cause mortality. Follow-up ended at death or on December 31, 2016. RESULTS: From January 1, 2005 to December 31, 2016, there were 2,037 cancer cases and 303 deaths (248 cancer-related deaths) among WTC-MMTP responders, 564 cancer cases, and 143 deaths (106 cancer-related deaths) among WTC-non-MMTP responders, and 574,075 cancer cases and 224,040 deaths (158,645 cancer-related deaths) among the NYS-non-responder population. Comparing WTC-MMTP responders with NYS-non-responders, the cancer-specific mortality hazard ratio (HR) was 0.72 (95% confidence interval [CI] = 0.64-0.82), and all-cause mortality HR was 0.64 (95% CI = 0.58-0.72). The cancer-specific HR was 0.94 (95% CI = 0.78-1.14), and all-cause mortality HR was 0.93 (95% CI = 0.79-1.10) comparing WTC-non-MMTP responders to the NYS-non-responder population. CONCLUSIONS: WTC-MMTP responders had lower mortality compared with NYS-non-responders, after controlling for demographic factors and temporal trends. There may be survival benefits from no-out-of-pocket-cost medical care which could have important implications for healthcare policy, however, other occupational and socioeconomic factors could have contributed to some of the observed survival advantage.

Impact of healthcare services on thyroid cancer incidence among World Trade Center-exposed rescue and recovery workers.

BACKGROUND: A recent study of World Trade Center (WTC)-exposed firefighters and emergency medical service workers demonstrated that elevated thyroid cancer incidence may be attributable to frequent medical testing, resulting in the identification of asymptomatic tumors. We expand on that study by comparing the incidence of thyroid cancer among three groups: WTC-exposed rescue/recovery workers enrolled in a New York State (NYS) WTC-medical monitoring and treatment program (MMTP); WTC-exposed rescue/recovery workers not enrolled in an MMTP (non-MMTP); and the NYS population. METHODS: Person-time began on 9/12/2001 or at enrollment in a WTC cohort and ended at death or on 12/31/2015. Cancer data were obtained through linkages with 13 state cancer registries. We used Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for MMTP and non-MMTP participants. NYS rates were used as the reference. To estimate potential changes over time in WTC-associated risk, change points in RRs were estimated using profile likelihood. RESULTS: The thyroid cancer incidence rate among MMTP participants was more than twice that of NYS population rates (RR = 2.31; 95% CI = 2.00-2.68). Non-MMTP participants had a risk similar to NYS (RR = 0.96; 95% CI = 0.72-1.28). We observed no change points in the follow-up period. CONCLUSION: Our findings support the hypothesis that no-cost screening (a benefit provided by WTC-MMTPs) is associated with elevated identification of thyroid cancer. Given the high survival rate for thyroid cancer, it is important to weigh the costs and benefits of treatment, as many of these cancers were asymptomatic and may have been detected incidentally.

Persistent mental and physical health impact of exposure to the September 11, 2001 World Trade Center terrorist attacks.

BACKGROUND: Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. METHODS: We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. RESULTS: In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. CONCLUSIONS: Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Behavior problems in adolescence and subsequent mental health in early adulthood: results from the World Trade Center Health Registry Cohort.

BACKGROUND: The present study examined the association between 9/11-related adolescent behavioral problems on mental health outcomes in early adulthood. METHODS: Data from enrollees of the World Trade Center Health Registry, who completed at least one adolescent (2006-2007 or 2011-2012) and adult survey (2011-2012 or 2015-2016), were analyzed. Adolescent behavioral difficulties were assessed using the adolescent-reported Strengths and Difficulties Questionnaire (SDQ). Adult mental health outcomes included binge drinking, smoking status history, 9/11-related post-traumatic stress disorder (PTSD), depression, and the self-reported number of physician mental health diagnoses. Multivariable regression was used to estimate associations of SDQ scores with mental health outcomes. RESULTS: Of the 297 enrollees, 16.8% (n = 50) had abnormal/borderline SDQ scores as an adolescent. Binge drinking was not associated with adolescent SDQ scores. Enrollees with abnormal/borderline SDQ scores as an adolescent were more likely to be a consistent smoker (odds ratio (OR): 5.6, 95% confidence interval (CI): 1.2-25.2), have probable PTSD (OR: 3.5, 95% CI: 1.3-9.8), depression (OR: 6.2, 95% CI: 2.7-13.9), and to have two or more self-reported physician-diagnosed mental health conditions as an adult (OR 5.6, 95% CI: 2.0-12.5). CONCLUSIONS: The findings of this study underscore the need to intervene early with children exposed to traumatic events so as to avert later adolescent and adult problem behaviors.

Mortality among rescue and recovery workers and community members exposed to the September 11, 2001 World Trade Center terrorist attacks, 2003-2014.

BACKGROUND: Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. MATERIALS AND METHODS: Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. RESULTS: We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. CONCLUSIONS: Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Comorbidity amplifies the effects of post-9/11 posttraumatic stress disorder trajectories on health-related quality of life.

PURPOSE: The present study aims to examine the impact of physical and mental health comorbidities on the association between post-9/11 posttraumatic stress disorder (PTSD) trajectories over 10 years and health-related quality of life (HRQOL) among 9/11-exposed persons. METHODS: 30,002 responding adult World Trade Center Health Registry enrollees reporting no pre-9/11 PTSD were studied. PTSD trajectories (chronic, delayed, remitted, no PTSD) were defined based on a 17-item PTSD Checklist-Specific to 9/11 across three waves of survey data. Three indicators of poor HRQOL were defined based on CDC HRQOL-4 measures. We computed age-adjusted prevalence of physical and mental health comorbidity (depression/anxiety) by PTSD trajectory and used modified Poisson regression to assess the effect of PTSD trajectory on poor HRQOL prevalence, accounting for comorbidity. RESULTS: Age-adjusted prevalence of overall comorbid conditions was 95.8 and 61.4% among the chronic and no-PTSD groups, respectively. Associations between 9/11-related PTSD trajectories and poor HRQOL were significant and became greater when comorbidity was included. Adjusted prevalence ratios were elevated for fair/poor health status (APR 7.3, 95% CI 6.5, 8.2), ≥ 14 unhealthy days (4.7; 95% CI 4.4, 5.1), and ≥ 14 activity limitation days during the last 30 days (9.6; 95% CI 8.1, 11.4) in the chronic PTSD group with physical and mental health comorbidity compared to those without PTSD and comorbidity; similar associations were observed for delayed PTSD. CONCLUSIONS: Ten years post-9/11 physical and mental health comorbidities have a substantial impact on the PTSD trajectories and HRQOL association. The need for early identification and treatment of PTSD and comorbidity should be emphasized to potentially improve HRQOL.

Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks.

OBJECTIVES: We studied the course of lower respiratory symptoms (LRS; cough, wheeze or dyspnoea) among community members exposed to the 9/11/2001 World Trade Center (WTC) attacks during a period of 12-13 years following the attacks, and evaluated risk factors for LRS persistence, including peripheral airway dysfunction and post-traumatic stress disorder (PTSD). METHODS: Non-smoking adult participants in a case-control study of post-9/11-onset LRS (exam 1, 2008-2010) were recruited for follow-up (exam 2, 2013-2014). Peripheral airway function was assessed with impulse oscillometry measures of R5 and R5-20. Probable PTSD was a PTSD checklist score ≥44 on a 2006-2007 questionnaire. RESULTS: Of 785 exam 1 participants, 545 (69%) completed exam 2. Most (321, 59%) were asymptomatic at all assessments. Among 192 participants with initial LRS, symptoms resolved for 110 (57%) by exam 2, 55 (29%) had persistent LRS and 27 (14%) had other patterns. The proportion with normal spirometry increased from 65% at exam 1 to 85% at exam 2 in the persistent LRS group (p<0.01) and was stable among asymptomatic participants and those with resolved LRS. By exam 2, spirometry results did not differ across symptom groups; however, R5 and R5-20 abnormalities were more common among participants with persistent LRS (56% and 46%, respectively) than among participants with resolved LRS (30%, p<0.01; 27%, p=0.03) or asymptomatic participants (20%, p<0.001; 8.2%, p<0.001). PTSD, R5 at exam 1, and R5-20 at exam 1 were each independently associated with persistent LRS. CONCLUSIONS: Peripheral airway dysfunction and PTSD may contribute to LRS persistence. Assessment of peripheral airway function detected pulmonary damage not evident on spirometry. Mental and physical healthcare for survivors of complex environmental disasters should be coordinated carefully.

Risk factors for and consequences of persistent lower respiratory symptoms among World Trade Center Health Registrants 10†years after the disaster.

OBJECTIVES: The prevalence of persistent lower respiratory symptoms (LRS) among rescue/recovery workers, local area workers, residents and passers-by in the World Trade Center Health Registry (WTCHR) was analysed to identify associated factors and to measure its effect on quality of life (QoL) 10 years after 9/11/2001. METHODS: This cross-sectional study included 18 913 adults who completed 3 WTCHR surveys (2003-2004 (Wave 1 (W1)), 2006-2007 (Wave 2 (W2)) and 2011-2012 (Wave 3 (W3)). LRS were defined as self-reported cough, wheeze, dyspnoea or inhaler use in the 30 days before survey. The prevalence of three LRS outcomes: LRS at W1; LRS at W1 and W2; and LRS at W1, W2 and W3 (persistent LRS) was compared with no LRS on WTC exposure and probable mental health conditions determined by standard screening tests. Diminished physical and mental health QoL measures were examined as potential LRS outcomes, using multivariable logistic and Poisson regression. RESULTS: Of the 4 outcomes, persistent LRS was reported by 14.7%. Adjusted ORs for disaster exposure, probable post-traumatic stress disorder (PTSD) at W2, lacking college education and obesity were incrementally higher moving from LRS at W1, LRS at W1 and W2 to persistent LRS. Half of those with persistent LRS were comorbid for probable PTSD, depression or generalised anxiety disorder. Enrollees with persistent LRS were 3 times more likely to report poor physical health and ∼ 50% more likely to report poor mental health than the no LRS group. CONCLUSIONS: LRS, accompanied by mental health conditions and decreased QoL, have persisted for at least 10 years after 9/11/2001. Affected adults require continuing surveillance and treatment.

Trajectories of PTSD Among Lower Manhattan Residents and Area Workers Following the 2001 World Trade Center Disaster, 2003-2012.

Group-based trajectory modeling was used to explore empirical trajectories of symptoms of posttraumatic stress disorder (PTSD) among 17,062 adult area residents/workers (nonrescue/recovery workers) enrolled in the World Trade Center (WTC) Health Registry using 3 administrations of the PTSD Checklist (PCL) over 9 years of observation. Six trajectories described PTSD over time: low-stable (48.9%), moderate-stable (28.3%), moderate-increasing (8.2%), high-stable (6.0%), high-decreasing (6.6 %), and very high-stable (2.0%). To examine factors associated with improving or worsening PTSD symptoms, groups with similar intercepts, but different trajectories were compared using bivariate analyses and logistic regression. The adjusted odds of being in the moderate-increasing relative to the moderate-stable group were significantly greater among enrollees reporting low social integration (OR = 2.18), WTC exposures (range = 1.34 to 1.53), job loss related to the September 11, 2001 disaster (OR = 1.41), or unmet mental health need/treatment (OR = 4.37). The odds of being in the high-stable relative to the high-decreasing group were significantly greater among enrollees reporting low social integration (OR = 2.23), WTC exposures (range = 1.39 to 1.45), or unmet mental health need/treatment (OR = 3.42). The influence of severe exposures, scarce personal/financial resources, and treatment barriers on PTSD trajectories suggest a need for early and ongoing PTSD screening postdisaster.

Effect of asthma and PTSD on persistence and onset of gastroesophageal reflux symptoms among adults exposed to the September 11, 2001, terrorist attacks.

BACKGROUND: Little is known about the direction of causality among asthma, posttraumatic stress disorder (PTSD), and onset of gastroesophageal reflux symptoms (GERS) after exposure to the 9/11/2001 World Trade Center (WTC) disaster. METHODS: Using data from the WTC Health Registry, we investigated the effects of early diagnosed post-9/11 asthma and PTSD on the late onset and persistence of GERS using log-binomial regression, and examined whether PTSD mediated the asthma-GERS association using structural equation modeling. RESULTS: Of 29,406 enrollees, 23% reported GERS at follow-up in 2011-2012. Early post-9/11 asthma and PTSD were each independently associated with both the persistence of GERS that was present at baseline and the development of GERS in persons without a prior history. PTSD mediated the association between early post-9/11 asthma and late-onset GERS. CONCLUSIONS: Clinicians should assess patients with post-9/11 GERS for comorbid asthma and PTSD, and plan medical care for these conditions in an integrated fashion. Am. J. Ind. Med. 59:805-814, 2016. © 2016 Wiley Periodicals, Inc.

Asthma among Staten Island fresh kills landfill and barge workers following the September 11, 2001 World Trade Center terrorist attacks.

BACKGROUND: Although airborne respiratory irritants at the World Trade Center (WTC) site have been associated with asthma among WTC Ground Zero workers, little is known about asthma associated with work at the Staten Island landfill or barges. METHODS: To evaluate the risk of asthma first diagnosed among Staten Island landfill and barge workers, we conducted a survey and multivariable logistic regression analysis regarding the association between Staten Island landfill and barge-related work exposures and the onset of post-9/11 asthma. RESULTS: Asthma newly diagnosed between September 11, 2001 and December 31, 2004 was reported by 100/1,836 (5.4%) enrollees. Jobs involving sifting, digging, welding, and steel cutting, enrollees with high landfill/barge exposure index scores or who were police and sanitation workers, and enrollees with probable posttraumatic stress disorder all had increased odds ratios for new-onset asthma. CONCLUSIONS: Post-9/11 asthma cumulative incidence among Staten Island landfill/barge workers was similar to that of other WTC disaster rescue and recovery workers. Am. J. Ind. Med. 59:795-804, 2016. © 2016 Wiley Periodicals, Inc.

Ten-year cancer incidence in rescue/recovery workers and civilians exposed to the September 11, 2001 terrorist attacks on the World Trade Center.

BACKGROUND: Cancer incidence in exposed rescue/recovery workers (RRWs) and civilians (non-RRWs) was previously reported through 2008. METHODS: We studied occurrence of first primary cancer among World Trade Center Health Registry enrollees through 2011 using adjusted standardized incidence ratios (SIRs), and the WTC-exposure-cancer association, using Cox proportional hazards models. RESULTS: All-cancer SIR was 1.11 (95% confidence interval (CI) 1.03-1.20) in RRWs, and 1.08 (95% CI 1.02-1.15) in non-RRWs. Prostate cancer and skin melanoma were significantly elevated in both populations. Thyroid cancer was significantly elevated only in RRWs while breast cancer and non-Hodgkin's lymphoma were significantly elevated only in non-RRWs. There was a significant exposure dose-response for bladder cancer among RRWs, and for skin melanoma among non-RRWs. CONCLUSIONS: We observed excesses of total and specific cancers in both populations, although the strength of the evidence for causal relationships to WTC exposures is somewhat limited. Continued monitoring of this population is indicated. Am. J. Ind. Med. 59:709-721, 2016. © 2016 Wiley Periodicals, Inc.

Factors associated with poor control of 9/11-related asthma 10-11 years after the 2001 World Trade Center terrorist attacks.

OBJECTIVE: To identify key factors associated with poor asthma control among adults in the World Trade Center (WTC) Health Registry, a longitudinal study of rescue/recovery workers and community members who were directly exposed to the 2001 WTC terrorist attacks and their aftermath. METHODS: We studied incident asthma diagnosed by a physician from 12 September 2001 through 31 December 2003 among participants aged ≥18 on 11 September 2001, as reported on an enrollment (2003-2004) or follow-up questionnaire. Based on modified National Asthma Education and Prevention Program criteria, asthma was considered controlled, poorly-controlled, or very poorly-controlled at the time of a 2011-2012 follow-up questionnaire. Probable post-traumatic stress disorder, depression, and generalized anxiety disorder were defined using validated scales. Self-reported gastroesophageal reflux symptoms (GERS) and obstructive sleep apnea (OSA) were obtained from questionnaire responses. Multinomial logistic regression was used to examine factors associated with poor or very poor asthma control. RESULTS: Among 2445 participants, 33.7% had poorly-controlled symptoms and 34.6% had very poorly-controlled symptoms in 2011-2012. Accounting for factors including age, education, body mass index, and smoking, there was a dose-response relationship between the number of mental health conditions and poorer asthma control. Participants with three mental health conditions had five times the odds of poor control and 13 times the odds of very poor control compared to participants without mental health comorbidities. GERS and OSA were significantly associated with poor or very poor control. CONCLUSIONS: Rates of poor asthma control were very high in this group with post-9/11 diagnosed asthma. Comprehensive care of 9/11-related asthma should include management of mental and physical health comorbidities.

Trajectories of Scores on a Screening Instrument for PTSD Among World Trade Center Rescue, Recovery, and Clean-Up Workers.

The longitudinal course of posttraumatic stress disorder (PTSD) over 8-9 years was examined among 16,488 rescue and recovery workers who responded to the events of September 11, 2001 (9/11) at the World Trade Center (WTC; New York, NY), and were enrolled in the World Trade Center Health Registry. Latent class growth analysis identified 5 groups of rescue and recovery workers with similar score trajectories at 3 administrations of the PTSD Checklist (PCL): low-stable (53.3%), moderate- stable (28.7%), moderate-increasing (6.4%), high-decreasing (7.7%), and high-stable (4.0%). Relative to the low-stable group, membership in higher risk groups was associated with 9/11-related exposures including duration of WTC work, with adjusted odds ratios ranging from 1.3 to 2.0, witnessing of horrific events (range = 1.3 to 2.1), being injured (range = 1.4 to 2.3), perceiving threat to life or safety (range = 2.2 to 5.2), bereavement (range = 1.6 to 4.8), and job loss due to 9/11 (range = 2.4 to 15.8). Within groups, higher PCL scores were associated with adverse social circumstances including lower social support, with B coefficients ranging from 0.2 to 0.6, divorce, separation, or widowhood (range = 0.4-0.7), and unemployment (range = 0.4-0.5). Given baseline, exposure-related, and contextual influences that affect divergent PTSD trajectories, screening for both PTSD and adverse circumstances should occur immediately, and at regular intervals postdisaster.

Posttraumatic Stress Disorder after Hurricane Sandy among Persons Exposed to the 9/11 Disaster.

BACKGROUND: Traumatic exposure during a hurricane is associated with adverse mental health conditions post-event. The World Trade Center Health Registry provided a sampling pool for a rapid survey of persons directly affected by Hurricane Sandy in the New York City (NYC) metropolitan area in late October 2012. This study evaluated the relationship between Sandy experiences and Sandy-related posttraumatic stress disorder (PTSD) among individuals previously exposed to the September 11, 2001 (9/11) disaster. METHODS: A total of 4,558 surveys were completed from April 10-November 7, 2013. After exclusions for missing data, the final sample included 2,214 (53.5%) respondents from FEMA-defined inundation zones and 1,923 (46.5%) from non-inundation zones. Sandy exposures included witnessing terrible events, Sandy-related injury, fearing for own life or safety of others, evacuation, living in a home that was flooded or damaged, property loss, and financial loss. Sandy-related PTSD was defined as a score of ≥44 on a Sandy-specific PTSD Checklist. RESULTS: PTSD prevalence was higher in the inundation zones (11.3%) and lower in the non-inundation zones (4.4%). The highest prevalence of Sandy-related PTSD was among individuals in the inundation zone who sustained an injury (31.2%), reported a history of 9/11-related PTSD (28.8%), or had low social support prior to the event (28.6%). In the inundation zones, significantly elevated adjusted odds of Sandy-related PTSD were observed among persons with a prior history of 9/11-related PTSD, low social support, and those who experienced a greater number of Sandy traumatic events. CONCLUSIONS: Sandy-related stress symptoms indicative of PTSD affected a significant proportion of persons who lived in flooded areas of the NYC metropolitan area. Prior 9/11-related PTSD increased the likelihood of Sandy-related PTSD, while social support was protective. Public health preparation for events similar to Sandy should incorporate outreach and linkages to care for persons with prior disaster-related trauma.

Chronic physical health consequences of being injured during the terrorist attacks on World Trade Center on September 11, 2001.

Few studies have focused on injuries from the World Trade Center disaster on September 11, 2001. Severe injury has health consequences, including an increased mortality risk 10 years after injury and the risk of mental health problems, such as posttraumatic stress disorder (PTSD). The World Trade Center Health Registry identified 14,087 persons with none of a selected group of preexisting chronic conditions before 2002 who were present during and soon after the World Trade Center attacks, 1,980 of whom reported sustaining 1 or more types of injury (e.g., a broken bone or burn). Survey data obtained during 2003-2004 and 2006-2007 were used to assess the odds of reporting a diagnosis of chronic conditions (heart disease, respiratory disease, diabetes, cancer) up to 5-6 years after the attacks. Number of injury types and probable PTSD were significantly associated with having any chronic conditions diagnosed in 2002-2007. Persons with multiple injuries and PTSD had a 3-fold higher risk of heart disease than did those with no injury and no PTSD, and persons with multiple injuries and with no PTSD had a 2-fold higher risk of respiratory diseases. The present study shows that injured persons with or without comorbid PTSD have a higher risk of developing chronic diseases. Clinicians should be aware of the heightened risk of chronic heart and respiratory conditions among injured persons.

Nonfatal injuries 1 week after hurricane sandy--New York city metropolitan area, October 2012.

On October 29, 2012, Hurricane Sandy (Sandy) made landfall in densely populated areas of New York, New Jersey, and Connecticut. Flooding affected 51 square miles (132 square kilometers) of New York City (NYC) and resulted in 43 deaths, many caused by drowning in the home, along with numerous storm-related injuries. Thousands of those affected were survivors of the World Trade Center (WTC) disaster of September 11, 2001 (9/11) who had previously enrolled in the WTC Health Registry (Registry) cohort study. To assess Sandy-related injuries and associated risk factors among those who lived in Hurricane Sandy-flooded areas and elsewhere, the NYC Department of Health and Mental Hygiene surveyed 8,870 WTC survivors, who had provided physical and mental health updates 8 to 16 months before Sandy. Approximately 10% of the respondents in flooded areas reported injuries in the first week after Sandy; nearly 75% of those had more than one injury. Injuries occurred during evacuation and clean-up/repair of damaged or destroyed homes. Hurricane preparation and precautionary messages emphasizing potential for injury hazards during both evacuation and clean-up or repair of damaged residences might help mitigate the occurrence and severity of injury after a hurricane.