World Trade Center disaster: assessment of responder occupations, work locations, and job tasks.

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.

Longitudinal assessment of spirometry in the World Trade Center medical monitoring program.

BACKGROUND: Multiple studies have demonstrated an initial high prevalence of spirometric abnormalities following World Trade Center (WTC) disaster exposure. We assessed prevalence of spirometric abnormalities and changes in spirometry between baseline and first follow-up evaluation in participants in the WTC Worker and Volunteer Medical Monitoring Program. We also determined the predictors of spirometric change between the two examinations. METHODS: Prebronchodilator and postbronchodilator spirometry, demographics, occupational history, smoking status, and respiratory symptoms and exposure onset were obtained at both examinations (about 3 years apart). RESULTS: At the second examination, 24.1% of individuals had abnormal spirometry findings. The predominant defect was a low FVC without obstruction (16.1%). Between examinations, the majority of individuals did not have a greater-than-expected decline in lung function. The mean declines in prebronchodilator FEV(1) and FVC were 13 mL/yr and 2 mL/yr, respectively (postbronchodilator results were similar and not reported). Significant predictors of greater average decline between examinations were lack of bronchodilator responsiveness at examination 1 and weight gain [corrected]. CONCLUSIONS: Elevated rates of spirometric abnormalities were present at both examinations, with reduced FVC most common. Although the majority had a normal decline in lung function, lack of bronchodilator response at examination 1 and weight gain were significantly associated with greater-than-normal lung function declines [corrected]. Due to the presence of spirometric abnormalities > 5 years after the disaster in many exposed individuals, longer-term monitoring of WTC responders is essential.

Standardization of spirometry in assessment of responders following man-made disasters: World Trade Center worker and volunteer medical screening program.

BACKGROUND: Spirometry is the most commonly used pulmonary function test to screen individuals for suspected lung disease. It is also used for screening workers with exposures to agents associated with pulmonary diseases. Although the American Thoracic Society (ATS) provides guidelines for spirometers and spirometry techniques, many factors are not standardized, so that results from individual pulmonary function laboratories vary substantially. These differences can create substantial difficulties in using data pooled from multiple sites to understand health consequences of disasters that involve exposures to pulmonary toxins. This article describes the approach used to minimize these differences for a consortium of institutions who are providing medical monitoring examinations to World Trade Center (WTC) responders. The protocol improved upon the minimal ATS guidelines. METHODS: Spirometric measurements were obtained before and after use of a bronchodilator. A fourth-generation spirometer was chosen that exceeded ATS spirometer accuracy standards. The accuracy was verified at the beginning of each day of testing. Technologists who performed the spirometry tests were centrally trained and certified and received regular reports on their performance. Reference values and normal ranges were obtained from the National Health and Nutrition Examination Survey (NHANES III) data set. A standardized interpretation flowchart was followed to reduce misclassification rates for airway obstruction and restriction. Patients with spirometric abnormalities were referred for more extensive diagnostic testing. RESULTS: More than 12,000 spirometry tests were performed during the first examination. The 20 spirometers used at the 6 participating institutions maintained accuracy within 3% for more than 4 years. Overall, more than 80% of the test sessions met ATS quality goals. Spirometry abnormality rates exceeded those obtained for adults who participated in the NHANES III survey. CONCLUSIONS: The program allowed standardization of the performance and interpretation of spirometry results across multiple institutions. This facilitated reliable and rapid diagnosis of lung disease in the large number of WTC responders screened. We recommend this approach for postdisaster pulmonary evaluations in other settings.

WTC medical monitoring and treatment program: comprehensive health care response in aftermath of disaster.

The attack on the World Trade Center (WTC) on September 11th, 2001 exposed thousands of individuals to an unprecedented mix of chemicals, combustion products and micronized building materials. Clinicians at the Mount Sinai Irving Selikoff Center for Occupational and Environmental Medicine, in partnership with affected stakeholder organizations, developed a medical screening program to evaluate the health status of workers and volunteers who spent time at the WTC site and thus sustained exposure in the aftermath of September 11th. Standardized questionnaires were adapted for use in this unique population and all clinicians underwent training to ensure comparability. The WTC Worker and Volunteer Medical Screening Program (MSP) received federal funding in April 2002 and examinations began in July 2002. The MSP and the follow up medical monitoring program has successfully recruited nearly 22,000 responders, and serves as a model for the rapid development of a medical screening program to assess the health of populations exposed to environmental hazards as a result of natural and man-made disasters. The MSP constitutes a successful screening program for WTC responders. We discuss the challenges that confronted the program; the absence of a prior model for the rapid development of a program to evaluate results from mixed chemical exposures; little documentation of the size of the exposed population or of who might have been exposed; and uncertainty about both the nature and potential severity of immediate and long-term health effects.

Workers' compensation experiences of computer users with musculoskeletal disorders.

BACKGROUND: Computer-related musculoskeletal disorders (MSDs) are of concern as computer use continues to increase. While MSDs are among the most disabling conditions in the United States, the workers' compensation (WC) experiences of individuals with these occupational disorders are not well described. METHODS: We conducted a study among 149 adults with work-related MSDs of the neck, upper back, or upper extremity related to computer use. Questionnaires were used to obtain information on subjective experiences with WC and economic issues. RESULTS: Seventy-four percent filed for WC. Twenty-five percent of all participants reported major financial difficulties after developing their MSD, though the majority filed for WC. Despite filing for WC, a large proportion relied partially on government, employer, or personal financial sources. Sixty-two percent reported that overall satisfaction with the WC insurer was poor. CONCLUSIONS: Findings indicate that a majority of participants filed for WC. Despite filing for WC financial difficulties after developing their MSD were considerable.

The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program.

BACKGROUND: Approximately 40,000 rescue and recovery workers were exposed to caustic dust and toxic pollutants following the 11 September 2001 attacks on the World Trade Center (WTC). These workers included traditional first responders, such as firefighters and police, and a diverse population of construction, utility, and public sector workers. METHODS: To characterize WTCrelated health effects, the WTC Worker and Volunteer Medical Screening Program was established. This multicenter clinical program provides free standardized examinations to responders. Examinations include medical, mental health, and exposure assessment questionnaires; physical examinations; spirometry; and chest X rays. RESULTS: Of 9,442 responders examined between July 2002 and April 2004, 69% reported new or worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of examination in 59% of these workers. Among those who had been asymptomatic before September 11, 61% developed respiratory symptoms while performing WTC work. Twenty-eight percent had abnormal spirometry; forced vital capacity (FVC) was low in 21%; and obstruction was present in 5%. Among nonsmokers, 27% had abnormal spirometry compared with 13% in the general U.S. population. Prevalence of low FVC among nonsmokers was 5-fold greater than in the U.S. population (20% vs. 4%). Respiratory symptoms and spirometry abnormalities were significantly associated with early arrival at the site. CONCLUSION: WTC responders had exposure-related increases in respiratory symptoms and pulmonary function test abnormalities that persisted up to 2.5 years after the attacks. Longterm medical monitoring is required to track persistence of these abnormalities and identify late effects, including possible malignancies. Lessons learned should guide future responses to civil disasters.

A mental health program for ground zero rescue and recovery workers: cases and observations.

Clinical vignettes from the World Trade Center Worker and Volunteer Mental Health Monitoring and Treatment Program at the Mount Sinai Medical Center in New York City are presented. The hospital-based program pairs mental health screenings with federally funded occupational medical screenings to identify persons with mental health problems related to their rescue and recovery roles. The program also provides on-site mental health treatment. The cases illustrate the diverse mental health needs of the rescue and recovery workers, some of whom initially sought treatment years after September 11, 2001. The cases show that in addition to symptoms of posttraumatic stress disorder, workers experienced survivor guilt, distressing memories of childhood trauma, shame associated with intense feelings, substance abuse relapse, psychosis, and problems with family relationships.