Estimation of Future Cancer Burden Among Rescue and Recovery Workers Exposed to the World Trade Center Disaster.

Importance: Elevated rates of cancer have been reported in individuals exposed to the World Trade Center (WTC) disaster, including Fire Department of the City of New York (FDNY) rescue and recovery workers. Objective: To project the future burden of cancer in WTC-exposed FDNY rescue and recovery workers by estimating the 20-year cancer incidence. Design, Setting, and Participants: A total of 14 474 WTC-exposed FDNY employees who were cancer-free on January 1, 2012; subgroup analyses were conducted of the cohort's white male population (n = 12 374). In this closed-cohort study, we projected cancer incidence for the January 1, 2012, to December 31, 2031, period. Simulations were run using demographic-specific New York City (NYC) cancer and national mortality rates for each individual, summed for the whole cohort, and performed 1000 times to produce mean estimates. Additional analyses in the subgroup of white men compared case counts produced by using 2007-2011 FDNY WTC Health Program (FDNY-WTCHP) cancer rates vs NYC rates. Average and 20-year aggregate costs of first-year cancer care were estimated using claims data. Exposures: World Trade Center disaster exposure defined as rescue and recovery work at the WTC site at any time from September 11, 2001, to July 25, 2002. Main Outcomes and Measures: (1) Projected number of incident cancers in the full cohort, based on NYC cancer rates; (2) cancer incidence estimates in the subgroup projected using FDNY-WTCHP vs NYC rates; and (3) estimated first-year treatment costs of incident cancers. Results: On January 1, 2012, the cohort was 96.8% male, 87.1% white, and had a mean (SD) age of 50.2 (9.2) years. The projected number of incident cancer cases was 2960 (95% CI, 2883-3037). In our subgroup analyses using FDNY-WTCHP vs NYC cancer rates, the projected number of new cases in white men was elevated (2714 [95% CI, 2638-2786] vs 2596 [95% CI, 2524-2668]). Accordingly, we expect more prostate (1437 [95% CI, 1383-1495] vs 863 [95% CI, 816-910]), thyroid (73 [95% CI, 60-86] vs 57 [95% CI, 44-69]), and melanoma cases (201 [95% CI, 179-223] vs 131 [95% CI, 112-150), but fewer lung (237 [95% CI, 212-262] vs 373 [95% CI, 343-405]), colorectal (172 [95% CI, 152-191] vs 267 [95% CI, 241-292]), and kidney cancers (66 [95% CI, 54-80] vs 132 [95% CI, 114-152]) (P < .001 for all comparisons). The estimated 20-year cost of first-year treatment was $235 835 412 (95% CI, $187 582 227-$284 088 597). Conclusions and Relevance: We project that the FDNY-WTCHP cohort will experience a greater cancer burden than would be expected from a demographically similar population. This underscores the importance of cancer prevention efforts and routine screening in WTC-exposed rescue and recovery workers.

The upper respiratory pyramid: early factors and later treatment utilization in World Trade Center exposed firefighters.

BACKGROUND: We investigated early post 9/11 factors that could predict rhinosinusitis healthcare utilization costs up to 11 years later in 8,079 World Trade Center-exposed rescue/recovery workers. METHODS: We used bivariate and multivariate analytic techniques to investigate utilization outcomes; we also used a pyramid framework to describe rhinosinusitis healthcare groups at early (by 9/11/2005) and late (by 9/11/2012) time points. RESULTS: Multivariate models showed that pre-9/11/2005 chronic rhinosinusitis diagnoses and nasal symptoms predicted final year healthcare utilization outcomes more than a decade after WTC exposure. The relative proportion of workers on each pyramid level changed significantly during the study period. CONCLUSIONS: Diagnoses of chronic rhinosinusitis within 4 years of a major inhalation event only partially explain future healthcare utilization. Exposure intensity, early symptoms and other factors must also be considered when anticipating future healthcare needs.

The respiratory pyramid: From symptoms to disease in World Trade Center exposed firefighters.

BACKGROUND: This study utilizes a four-level pyramid framework to understand the relationship between symptom reports and/or abnormal pulmonary function and diagnoses of airway diseases (AD), including asthma, recurrent bronchitis and COPD/emphysema in WTC-exposed firefighters. We compare the distribution of pyramid levels at two time-points: by 9/11/2005 and by 9/11/2010. METHODS: We studied 6,931 WTC-exposed FDNY firefighters who completed a monitoring exam during the early period and at least two additional follow-up exams 9/11/2005-9/11/2010. RESULTS: By 9/11/2005 the pyramid structure was as follows: 4,039 (58.3%) in Level 1, no respiratory evaluation or treatment; 1,608 (23.2%) in Level 2, evaluation or treatment without AD diagnosis; 1,005 (14.5%) in Level 3, a single AD diagnosis (asthma, emphysema/COPD, or recurrent bronchitis); 279 (4.0%) in Level 4, asthma and another AD. By 9/11/2010, the pyramid distribution changed considerably, with Level 1 decreasing to 2,612 (37.7% of the cohort), and Levels 3 (N = 1,530) and 4 (N = 796) increasing to 22.1% and 11.5% of the cohort, respectively. Symptoms, spirometry measurements and healthcare utilization were associated with higher pyramid levels. CONCLUSIONS: Respiratory diagnoses, even four years after a major inhalation event, are not the only drivers of future healthcare utilization. Symptoms and abnormal FEV-1 values must also be considered if clinicians and healthcare administrators are to accurately anticipate future treatment needs, years after initial exposure.

Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness.

BACKGROUND: On August 14, 2003, the United States and Canada suffered the largest power failure in history. We report the effects of this blackout on New York City's healthcare system by examining the following: 1) citywide 911 emergency medical service (EMS) calls and ambulance responses; and 2) emergency department (ED) visits and hospital admissions to one of New York City's largest hospitals. METHODS: Citywide EMS calls and ambulance responses were categorized by 911 call type. Montefiore Medical Center (MMC) ED visits and hospital admissions were categorized by diagnosis and physician-reviewed for relationship to the blackout. Comparisons were made to the week pre- and postblackout. RESULTS: Citywide EMS calls numbered 5,299 on August 14, 2003, and 5,021 on August 15, 2003, a 58% increase (p < .001). During the blackout, there were increases in "respiratory" (189%; p < .001), "cardiac" (68%; p = .016), and "other" (40%; p < .001) EMS call categories, but when expressed as a percent of daily totals, "cardiac" was no longer significant. The MMC-ED reflected this surge with only "respiratory" visits significantly increased (expressed as percent of daily total visits; p < .001). Respiratory device failure (mechanical ventilators, positive pressure breathing assist devices, nebulizers, and oxygen compressors) was responsible for the greatest burden (65 MMC-ED visits, with 37 admissions) as compared with 0 pre- and postblackout. CONCLUSIONS: The blackout dramatically increased EMS and hospital activity, with unexpected increases resulting from respiratory device failures in community-based patients. Our findings suggest that current capacity to respond to public health emergencies could be easily overwhelmed by widespread/prolonged power failure(s). Disaster preparedness planning would be greatly enhanced if fully operational, backup power systems were mandated, not only for acute care facilities, but also for community-based patients dependent on electrically powered lifesaving devices.

Induced sputum assessment in New York City firefighters exposed to World Trade Center dust.

New York City Firefighters (FDNY-FFs) were exposed to particulate matter and combustion/pyrolysis products during and after the World Trade Center (WTC) collapse. Ten months after the collapse, induced sputum (IS) samples were obtained from 39 highly exposed FDNY-FFs (caught in the dust cloud during the collapse on 11 September 2001) and compared to controls to determine whether a unique pattern of inflammation and particulate matter deposition, compatible with WTC dust, was present. Control subjects were 12 Tel-Aviv, Israel, firefighters (TA-FFs) and 8 Israeli healthcare workers who were not exposed to WTC dust. All controls volunteered for this study, had never smoked, and did not have respiratory illness. IS was processed by conventional methods. Retrieved cells were differentially counted, and metalloproteinase-9 (MMP-9), particle size distribution (PSD), and mineral composition were measured. Differential cell counts of FDNY-FF IS differed from those of health care worker controls (p < 0.05) but not from those of TA-FFs. Percentages of neutrophils and eosinophils increased with greater intensity of WTC exposure (< 10 workdays or greater than or equal to 10 workdays; neutrophils p = 0.046; eosinophils p = 0.038). MMP-9 levels positively correlated to neutrophil counts (p = 0.002; r = 0.449). Particles were larger and more irregularly shaped in FDNY-FFs (1-50 microm; zinc, mercury, gold, tin, silver) than in TA-FFs (1-10 microm; silica, clays). PSD was similar to that of WTC dust samples. In conclusion, IS from highly exposed FDNY-FFs demonstrated inflammation, PSD, and particle composition that was different from nonexposed controls and consistent with WTC dust exposure.

Assessment of health effects in New York City firefighters after exposure to polychlorinated biphenyls (PCBs) and polychlorinated dibenzofurans (PCDFs): the Staten Island Transformer Fire Health Surveillance Project.

Following an electrical transformer fire in Staten Island, New York, a health surveillance program was established for 60 New York City firefighters and emergency medical technicians exposed to polychlorinated biphenyls (PCBs) and polychlorinated dibenzofurans (PCDFs). Exposure potential was documented after high levels of PCBs and PCDFs were found on transformer and firefighters' uniforms. Personnel received comprehensive medical examinations, and the results were compared with preexposure values. Serum was analyzed for PCBs, PCDFs, and polychlorinated dibenzo-p-dioxins (PCDDs). Follow-up was conducted 9 mo later. Thirty-two of 58 (55%) firefighters reported initial symptoms, and 3 firefighters required brief medical leave. Pulmonary functions, exercise performance, serum liver functions, and serum lipid profiles were normal or unchanged from preexposure baselines. Serum PCBs averaged 2.92 +/- 1.96 ppb (range = 1.9-11.0 ppb). Five (8%) had serum PCBs that were greater than or equal to 6 ppb. Eight (73%) had a significant decrease (p = .05) in serum PCB level at the time of follow-up. Serum toxic equivalency (TEQ [1998 World Health Organization]) for total PCDDs and PCDFs averaged 39.0 +/- 21.5 (n = 48). Eighteen (38%) had elevated TEQs (i.e., > 40). All firefighters had no short-term heath effects. Modern firefighting uniforms are not meant to replace HAZMAT suits, but these uniforms provide protection from this chemical exposure for most firefighters.