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.

Lung function in rescue workers at the World Trade Center after 7 years.

BACKGROUND: The terrorist attacks on the World Trade Center on September 11, 2001, exposed thousands of Fire Department of New York City (FDNY) rescue workers to dust, leading to substantial declines in lung function in the first year. We sought to determine the longer-term effects of exposure. METHODS: Using linear mixed models, we analyzed the forced expiratory volume in 1 second (FEV(1)) of both active and retired FDNY rescue workers on the basis of spirometry routinely performed at intervals of 12 to 18 months from March 12, 2000, to September 11, 2008. RESULTS: Of the 13,954 FDNY workers who were present at the World Trade Center between September 11, 2001, and September 24, 2001, a total of 12,781 (91.6%) participated in this study, contributing 61,746 quality-screened spirometric measurements. The median follow-up was 6.1 years for firefighters and 6.4 years for emergency-medical-services (EMS) workers. In the first year, the mean FEV(1) decreased significantly for all workers, more for firefighters who had never smoked (a reduction of 439 ml; 95% confidence interval [CI], 408 to 471) than for EMS workers who had never smoked (a reduction of 267 ml; 95% CI, 263 to 271) (P<0.001 for both comparisons). There was little or no recovery in FEV(1) during the subsequent 6 years, with a mean annualized reduction in FEV(1) of 25 ml per year for firefighters and 40 ml per year for EMS workers. The proportion of workers who had never smoked and who had an FEV(1) below the lower limit of the normal range increased during the first year, from 3% to 18% for firefighters and from 12% to 22% for EMS workers, stabilizing at about 13% for firefighters and 22% for EMS workers during the subsequent 6 years. CONCLUSIONS: Exposure to World Trade Center dust led to large declines in FEV(1) for FDNY rescue workers during the first year. Overall, these declines were persistent, without recovery over the next 6 years, leaving a substantial proportion of workers with abnormal lung function.

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.

A computerized, self-administered questionnaire to evaluate posttraumatic stress among firefighters after the World Trade Center collapse.

OBJECTIVES: We sought to determine the frequency of psychological symptoms and elevated posttraumatic stress disorder (PTSD) risk among New York City firefighters after the World Trade Center (WTC) attack and whether these measures were associated with Counseling Services Unit (CSU) use or mental health-related medical leave over the first 2.5 years after the attack. METHODS: Shortly after the WTC attack, a computerized, binary-response screening questionnaire was administered. Exposure assessment included WTC arrival time and "loss of a co-worker while working at the collapse." We determined elevated PTSD risk using thresholds derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and a sensitivity-specificity analysis. RESULTS: Of 8487 participants, 76% reported at least 1 symptom, 1016 (12%) met criteria for elevated PTSD risk, and 2389 (28%) self-referred to the CSU, a 5-fold increase from before the attack. Higher scores were associated with CSU use, functional job impairment, and mental health-related medical leave. Exposure-response gradients were significant for all outcomes. CONCLUSIONS: This screening tool effectively identified elevated PTSD risk, higher CSU use, and functional impairment among firefighters and therefore may be useful in allocating scarce postdisaster mental health resources.

Comorbid trends in World Trade Center cough syndrome and probable posttraumatic stress disorder in firefighters.

BACKGROUND: We describe the relationship between World Trade Center (WTC) cough syndrome symptoms, pulmonary function, and symptoms consistent with probable posttraumatic stress disorder (PTSD) in WTC-exposed firefighters in the first year post-September 11, 2001 (baseline), and 3 to 4 years later (follow-up). METHODS: Five thousand three hundred sixty-three firefighters completed pulmonary function tests (PFTs) and questionnaires at both times. Relationships among WTC cough syndrome, probable PTSD, and PFTs were analyzed using simple and multivariable models. We also examined the effects of cofactors, including WTC exposure. RESULTS: WTC cough syndrome was found in 1,561 firefighters (29.1%) at baseline and 1,186 (22.1%) at follow-up, including 559 with delayed onset (present only at follow-up). Probable PTSD was found in 458 firefighters (8.5%) at baseline and 548 (10.2%) at follow-up, including 343 with delayed onset. Baseline PTSD symptom counts and probable PTSD were associated with WTC cough syndrome at baseline, at follow-up, and in those with delayed-onset WTC cough syndrome. Similarly, WTC cough syndrome symptom counts and WTC cough syndrome at baseline were associated with probable PTSD at baseline, at follow-up, and in those with delayed-onset probable PTSD. WTC arrival time and work duration were cofactors of both outcomes. A small but consistent association existed between pulmonary function and WTC cough syndrome, but none with PTSD. CONCLUSIONS: The study showed a moderate association between WTC cough syndrome and probable PTSD. The presence of one contributed to the likelihood of the other, even after adjustment for shared cofactors such as WTC exposure.