The World Trade Center Health Program: Obstructive sleep apnea best practices.

The events of September 11, 2001 exposed nearly half a million community residents and workers engaged in rescue and recovery and clean-up to dust, debris and toxic chemicals, as well as psychologic and physical stressors. Early studies showed an excess of aerodigestive diseases including rhinosinusitis and gastroesophageal reflux. Several studies of World Trade Center (WTC) responders report an excess of obstructive sleep apnea among patients who developed new onset or worsening chronic rhinosinusitis. High quality clinical diagnostic and treatment guidelines are available from The American Academy of Sleep Medicine and the Department of Veterans Affairs/Department of Defense. For enrolled members, the WTC program covers diagnostic evaluation and treatment for sleep apnea in members diagnosed with WTC-related upper and lower respiratory disease and gastroesophageal reflux.

Incidence and Predictors of COVID-19 Infection in Prison Healthcare Workers.

OBJECTIVE: The aim of the study is to assess the predictors of SARS-CoV-2 infection among correctional healthcare workers (HCWs). METHODS: We conducted a retrospective chart review to describe the demographic and workplace characteristics of New Jersey correctional HCWs between March 15, 2020, and August 31, 2020, using univariate and multivariable analysis. RESULTS: Among 822 HCWs, patient-facing staff had the highest incidence of infection (7.2%). Associated risk factors include being Black and working in a maximum-security prison. There were few statistically significant findings due to small total numbers ( n = 47) that tested positive. CONCLUSIONS: Correctional HCWs' challenging work environment creates unique risk factors for infection with the SARS-CoV-2 virus. Administrative measures taken by the department of corrections may have a significant role in curbing the spread of infection. The findings can help focus preventive measures for reducing the spread of COVID-19 in this unique population.

World Trade Center Health Program best practices for the diagnosis and treatment of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is one of the most common health conditions reported among persons exposed to the dust, debris and chemicals after the September 11, 2001 attacks in the United States. In the 9/11-exposed population, GERD is often found to be co-morbid with other conditions, such as asthma, post-traumatic stress disorder, and obesity. High-quality clinical practice guidelines for GERD are available from the American College of Gastroenterology. GERD diagnostic services and medically necessary treatment are covered by the WTC Health Program for persons who meet eligibility criteria.

The World Trade Center Health Program: an introduction to best practices.

More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.

Prevalence and correlates of suicidal ideation in World Trade Center responders: Results from a population-based health monitoring cohort.

BACKGROUND: Suicidal ideation (SI) is an early risk factor for suicide among disaster responders. To date, however, no known study has examined the prevalence, and pre-, peri-, and post-disaster risk correlates of SI in World Trade Center (WTC) responders, one of the largest disaster response populations in U.S. METHODS: The prevalence, and pre-, peri- and post-event correlates of SI were assessed in a population-based health monitoring cohort of 14,314 police responders and 16,389 non-traditional responders (e.g., construction workers) who engaged in response, recovery, and clean-up efforts following the 9/11/2001 terrorist attacks on the WTC. Multivariable analyses were conducted to identify correlates and individual psychiatric symptoms associated with SI in each group. RESULTS: A total 12.5% of non-traditional and 2.2% of police WTC responders reported SI. Depression, functional impairment, alcohol use problems, and lower family support while working at the WTC site were associated with SI in both groups of responders. Symptom-level analyses revealed that three symptoms accounted for approximately half of the variance in SI for both groups-feeling bad about oneself, or that one has let down oneself or family; feeling down, depressed, or hopeless; and sense of foreshortened future (44.7% in non-traditional and 71% in police). LIMITATIONS: Use of self-report measures and potentially limited generalizability. CONCLUSIONS: SI is prevalent in WTC disaster responders, particularly non-traditional responders. Post-9/11 psychiatric symptoms reflecting guilt, shame, hopelessness, and associated functional impairment are most strongly linked to SI, suggesting that interventions targeting these factors may help mitigate suicide risk in this population.

Altered gene expression and PTSD symptom dimensions in World Trade Center responders.

Despite experiencing a significant trauma, only a subset of World Trade Center (WTC) rescue and recovery workers developed posttraumatic stress disorder (PTSD). Identification of biomarkers is critical to the development of targeted interventions for treating disaster responders and potentially preventing the development of PTSD in this population. Analysis of gene expression from these individuals can help in identifying biomarkers of PTSD. We established a well-phenotyped sample of 371 WTC responders, recruited from a longitudinal WTC responder cohort using stratified random sampling, by obtaining blood, self-reported and clinical interview data. Using bulk RNA-sequencing from whole blood, we examined the association between gene expression and WTC-related PTSD symptom severity on (i) highest lifetime Clinician-Administered PTSD Scale (CAPS) score, (ii) past-month CAPS score, and (iii) PTSD symptom dimensions using a 5-factor model of re-experiencing, avoidance, emotional numbing, dysphoric arousal and anxious arousal symptoms. We corrected for sex, age, genotype-derived principal components and surrogate variables. Finally, we performed a meta-analysis with existing PTSD studies (total N = 1016), using case/control status as the predictor and correcting for these variables. We identified 66 genes significantly associated with total highest lifetime CAPS score (FDR-corrected p < 0.05), and 31 genes associated with total past-month CAPS score. Our more granular analyses of PTSD symptom dimensions identified additional genes that did not reach statistical significance in our analyses with total CAPS scores. In particular, we identified 82 genes significantly associated with lifetime anxious arousal symptoms. Several genes significantly associated with multiple PTSD symptom dimensions and total lifetime CAPS score (SERPINA1, RPS6KA1, and STAT3) have been previously associated with PTSD. Geneset enrichment of these findings has identified pathways significant in metabolism, immune signaling, other psychiatric disorders, neurological signaling, and cellular structure. Our meta-analysis revealed 10 genes that reached genome-wide significance, all of which were downregulated in cases compared to controls (CIRBP, TMSB10, FCGRT, CLIC1, RPS6KB2, HNRNPUL1, ALDOA, NACA, ZNF429 and COPE). Additionally, cellular deconvolution highlighted an enrichment in CD4 T cells and eosinophils in responders with PTSD compared to controls. The distinction in significant genes between total lifetime CAPS score and the anxious arousal symptom dimension of PTSD highlights a potential biological difference in the mechanism underlying the heterogeneity of the PTSD phenotype. Future studies should be clear about methods used to analyze PTSD status, as phenotypes based on PTSD symptom dimensions may yield different gene sets than combined CAPS score analysis. Potential biomarkers implicated from our meta-analysis may help improve therapeutic target development for PTSD.

Race/ethnic differences in prevalence and correlates of posttraumatic stress disorder in World Trade Center responders: Results from a population-based, health monitoring cohort.

OBJECTIVE: This study evaluated race/ethnic differences in the prevalence and correlates of World Trade Center (WTC) related posttraumatic stress disorder (PTSD) in WTC responders. METHOD: Data were analyzed from a population-based, health monitoring cohort of 15,440 nontraditional (i.e., construction workers) and 13,403 police WTC responders. RESULTS: Among nontraditional responders, the prevalence of WTC-related PTSD was highest in Latino/a (40.4%) versus Black (27.3%) and White (26.5%) responders; among police responders, Latino/a (10.4%) responders also had higher prevalence of PTSD relative to Black (9.8%) and White (8.7%) responders. However, multivariable analyses revealed that prior psychiatric diagnosis, greater severity of WTC-related exposures, post-9/11 stressful life events, (in police responders only) older age, and (in nontraditional responders only) lower income and education levels accounted for substantially higher prevalence of WTC-related PTSD across ethnic/racial groups. Additionally, among nontraditional responders, subgroups with added risk included responders who were: Latino/a or White had high post-911 stressful events; Latino/a or Black and had pre-9/11 psychiatric history; and Latinas. Among police responders, subgroups with added risk were Latino/a or Black police with a low annual income. CONCLUSIONS: Collectively, results of this study underscore the burden of differential vulnerability that can contribute to higher prevalence of PTSD in certain cultural subgroups following large magnitude traumatic events. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Autoimmune conditions in the World Trade Center general responder cohort: A nested case-control and standardized incidence ratio analysis.

BACKGROUND: The World Trade Center (WTC) general responder cohort (GRC) was exposed to environmental toxins possibly associated with increased risk of developing autoimmune conditions. OBJECTIVES: Two study designs were used to assess incidence and risks of autoimmune conditions in the GRC. METHODS: Three clinically trained professionals established the status of possible GRC cases of autoimmune disorders adhering to diagnostic criteria, supplemented, as needed, by specialists' review of consenting responders' medical records. Nested case-control analyses using conditional logistic regression estimated the risk associated with high WTC exposure (being in the 9/11/2001 dust cloud or ≥median days' response worked) compared with low WTC exposure (all other GRC members'). Four controls were matched to each case on age at case diagnosis (±2 years), sex, race/ethnicity, and year of program enrollment. Sex-specific and sensitivity analyses were performed. GRC age- and sex-adjusted standardized incidence ratios (SIRs) were compared with the Rochester Epidemiology Project (REP). Complete REP inpatient and outpatient medical records were reviewed by specialists. Conditions meeting standardized criteria on ≥2 visits were classified as REP confirmed cases. RESULTS: Six hundred and twenty-eight responders were diagnosed with autoimmune conditions between 2002 and 2017. In the nested case-control analyses, high WTC exposure was not associated with autoimmune domains and conditions (rheumatologic domain odds ratio [OR] = 1.03, 95% confidence interval [CI] = 0.77, 1.37; rheumatoid arthritis OR = 1.12, 95% CI = 0.70, 1.77). GRC members had lower SIR than REP. Women's risks were generally greater than men's. CONCLUSIONS: The study found no statistically significant increased risk of autoimmune conditions with WTC exposures.

The Critical Importance of Molecular Biomarkers and Imaging in the Study of Electrohypersensitivity. A Scientific Consensus International Report.

Clinical research aiming at objectively identifying and characterizing diseases via clinical observations and biological and radiological findings is a critical initial research step when establishing objective diagnostic criteria and treatments. Failure to first define such diagnostic criteria may lead research on pathogenesis and etiology to serious confounding biases and erroneous medical interpretations. This is particularly the case for electrohypersensitivity (EHS) and more particularly for the so-called "provocation tests", which do not investigate the causal origin of EHS but rather the EHS-associated particular environmental intolerance state with hypersensitivity to man-made electromagnetic fields (EMF). However, because those tests depend on multiple EMF-associated physical and biological parameters and have been conducted in patients without having first defined EHS objectively and/or endpoints adequately, they cannot presently be considered to be valid pathogenesis research methodologies. Consequently, the negative results obtained by these tests do not preclude a role of EMF exposure as a symptomatic trigger in EHS patients. Moreover, there is no proof that EHS symptoms or EHS itself are caused by psychosomatic or nocebo effects. This international consensus report pleads for the acknowledgement of EHS as a distinct neuropathological disorder and for its inclusion in the WHO International Classification of Diseases.

Perceived Health Risks Among Firefighters; The New Jersey Firefighter Health Survey.

OBJECTIVE: There is a growing literature on the risk of chronic disease among firefighters, including cardiovascular disease (CVD) and cancer. However there is little information on firefighter's perception thereof. METHODS: Firefighters attending a union convention in New Jersey completed a survey with four domains: firefighting experience; perceived additional risk for chronic diseases (six-point Likert scale); cancer screening history; demographics, and risk behaviors. RESULTS: Among 167 enrolled firefighters, all were men and 86.6% active career. Median perceived risk ranged from high risk (colon, hematologic, breast, prostate, and testicular cancers) to very high risk (CVD, pulmonary diseases, all cancers, lung and oral cancer). CONCLUSIONS: NJ Firefighters attributed considerable additional risk to acquiring chronic disease as a result of their firefighting activities. Understanding firefighter perceptions of their own morbidity and mortality will help develop future firefighter preparatory programs.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort.

BACKGROUND: Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers. OBJECTIVE: To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders. METHODS: Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders. RESULTS: Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers. CONCLUSIONS: Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.

An Assessment of Healthcare Access and Utilization in the World Trade Center Health Program.

OBJECTIVE: Access to healthcare, a national priority, may be better understood through medical surveillance programs like the World Trade Center Health Program (WTCHP). METHODS: Measures of healthcare access and utilization for 1159 9/11 rescue and recovery workers ("responders") at the Rutgers Clinical Center of Excellence (CCE) were assessed using negative binomial modeling of the Benefits Eligibility Assessment Screening Tool and compared with 174 9/11 responders in the 2017 New York City Community Health Survey (NYCCHS) using z-testing. RESULTS: Approximately 10.8% of Rutgers CCE respondents lacked at least one aspect of healthcare access. Problems accessing healthcare and basic needs were positively associated with CCE utilization and differed between Rutgers CCE and NYCCHS respondents. CONCLUSIONS: Some 9/11 responders bridge healthcare access gaps via participation in the WTCHP. Surveillance survey tools may help to identify healthcare disparities.

Cardiovascular disease in the World Trade Center Health Program General Responder Cohort.

BACKGROUND: Over 90,000 rescue and recovery responders to the September 2001 World Trade Center (WTC) attacks were exposed to toxic materials that can impair cardiac function and increase cardiovascular disease (CVD) risk. We examined WTC-related exposures association with annual and cumulative CVD incidence and risk over 17 years in the WTC Health Program (HP) General Responder Cohort (GRC). METHODS: Post 9/11 first occurrence of CVD was assessed in 37,725 responders from self-reported physician diagnosis of, or current treatment for, coronary artery disease, myocardial infarction, stroke and/or congestive heart failure from WTCHP GRC monitoring visits. Kaplan-Meier estimates of CVD incidence used the generalized Wilcoxon test statistic to account for censored data. Cox proportional hazards regression analyses estimated the CVD hazard ratio associated with 9/11/2001 arrival in responders with and without dust cloud exposure, compared with arrival on or after 9/12/2001. Additional analyses adjusted for comorbidities. RESULTS: To date, 6.3% reported new CVD. In covariate-adjusted analyses, men's CVD 9/11/2001 arrival risks were 1.40 (95% confidence interval [CI] = 1.26, 1.56) and 1.43 (95% CI = 1.29, 1.58) and women's were 2.16 (95% CI = 1.49, 3.11) and 1.59 (95% CI = 1.11, 2.27) with and without dust cloud exposure, respectively. Protective service employment on 9/11 had higher CVD risk. CONCLUSIONS: WTCHP GRC members with 9/11/2001 exposures had substantially higher CVD risk than those initiating work afterward, consistent with observations among WTC-exposed New York City firefighters. Women's risk was greater than that of men's. GRC-elevated CVD risk may also be occurring at a younger age than in the general population.

Acculturation, coping, and PTSD in Hispanic 9/11 rescue and recovery workers.

Objective: Research examining the responders of the World Trade Center terrorist attacks of 9/11 has found that Hispanic responders are at greater risk for posttraumatic stress disorder (PTSD) than non-Hispanic White responders. However, no studies have examined how acculturation may influence the relationship between coping and PTSD in Hispanic 9/11 responders. This novel study is the first to examine differences in coping and PTSD among Hispanic responders by level of acculturation. Methods: The sample is composed of 845 Hispanic 9/11 responders who were seen at the World Trade Center Health Program and participated in a web-based survey. Using logistic and multiple linear regression, we examined how acculturation is related to their coping strategies and risk for PTSD. We also tested for interaction to examine whether level of acculturation moderated the relationship between coping and PTSD symptom severity. Results: Key findings revealed that higher acculturation is associated with the use of substances, venting, and humor to cope, while lower acculturation is associated with the use of active coping and self-distraction in this sample. We also found that less acculturated responders were more likely to experience more severe PTSD. Lastly, our findings revealed that Hispanics who are more acculturated and used substances to cope had more severe PTSD than less acculturated responders. Conclusion: These findings highlight the need to consider the role of acculturation in Hispanic responders' coping and PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

PAP Adherence and Nasal Resistance. A Randomized Controlled Trial of CPAPflex versus CPAP in World Trade Center Responders.

Rationale: Continuous positive airway pressure (CPAP) adherence is often poor in obstructive sleep apnea (OSA) and may be influenced by nasal resistance. CPAP with a reduction of expiratory pressure (CPAPflex) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup.Objectives: To evaluate the association of positive airway pressure (PAP) treatment adherence to nasal resistance and examine if CPAPflex improves adherence over CPAP in subjects with high nasal resistance.Methods: A randomized double-blind crossover trial of 4 weeks each of CPAPflex versus CPAP in subjects exposed to World Trade Center dust with OSA stratified by nasal resistance, measured by 4-Phase Rhinomanometry.Results: Three hundred seventeen subjects with OSA (mean, apnea-hypopnea index with 4% O2 desaturation for hypopnea = 17 ± 14/h) were randomized. Overall, PAP adherence was poor, but adherence to CPAP (n = 239; mean hours per night [95% confidence interval (CI)]), 1.97 h (1.68 to 2.26) was greater than adherence to CPAPflex (n = 249; 1.65 h [1.39 to 1.91]; difference of 0.31 h [0.03; 0.6]; P < 0.05). Contrary to our hypothesis there was no correlation between nasal resistance and adherence to CPAP (r = 0.098; P = not significant) or CPAPflex (r = 0.056; P = not significant). There was no difference in adherence between CPAP and CPAPflex (mean Δ hours [95% CI]) in subjects with low resistance (0.33 h [-0.10 to 0.76]) or high nasal resistance (0.26 h [-0.14 to 0.66]). No significant differences were observed in any of the secondary outcomes between PAP modes.Conclusions: Contrary to expectations, our data do not show better adherence to CPAPflex than to CPAP in subjects with high or low nasal resistance and do show clinically insignificant better adherence overall with CPAP.Clinical trial registered with www.clinicaltrials.gov (NCT01753999).

Retrospective Assessment of Risk Factors for Head and Neck Cancer Among World Trade Center General Responders.

Objective: To assess the reliability of a questionnaire designed to reconstruct risk factors for head and neck cancer relative to the 9/11 World Trade Center (WTC) response and over the lifetime. Methods: As part of a nested case-control study, 200 WTC Health Program (WTCHP) General Responder Cohort (GRC) members completed a newly-developed study questionnaire via telephone (with a trained interviewer) or online (self-administered). We assessed agreement between measures of tobacco and alcohol use in our questionnaire results and data collected previously during WTCHP-GRC monitoring visits using Cohens Kappa (κ) and intraclass correlation coefficient (ICC) for categorical and continuous measures, respectively. We compared agreement by disease status, survey mode, and year of WTCHP enrollment. Results: We observed high agreement between measures of lifetime, pre-WTC, and post-WTC smoking prevalence (all κ > 0.85) and smoking duration (all ICC > 0.84). There was moderate agreement between measures of smoking frequency (ICC: 0.61-0.73). Agreement between measures of smoking frequency, but not duration, differed by disease status, and agreement between smoking measures was higher for participants who completed our survey by phone than by web. Among cases, there were no differences based on enrollment in the WTCHP before or after diagnosis. Conclusion: Agreement between measures was generally high, although potential reporting bias and a mode effect that should be considered when interpreting analyses of self-reported data in this population; however differential misclassification appears to be minimal. Our questionnaire may be useful for future studies examining similar behavioral risk factors among disaster-exposed populations.

Electromagnetic hypersensitivity (EHS, microwave syndrome) - Review of mechanisms.

Electromagnetic hypersensitivity (EHS), known in the past as "Microwave syndrome", is a clinical syndrome characterized by the presence of a wide spectrum of non-specific multiple organ symptoms, typically including central nervous system symptoms, that occur following the patient's acute or chronic exposure to electromagnetic fields in the environment or in occupational settings. Numerous studies have shown biological effects at the cellular level of electromagnetic fields (EMF) at magnetic (ELF) and radio-frequency (RF) frequencies in extremely low intensities. Many of the mechanisms described for Multiple Chemical Sensitivity (MCS) apply with modification to EHS. Repeated exposures result in sensitization and consequent enhancement of response. Many hypersensitive patients appear to have impaired detoxification systems that become overloaded by excessive oxidative stress. EMF can induce changes in calcium signaling cascades, significant activation of free radical processes and overproduction of reactive oxygen species (ROS) in living cells as well as altered neurological and cognitive functions and disruption of the blood-brain barrier. Magnetite crystals absorbed from combustion air pollution could have an important role in brain effects of EMF. Autonomic nervous system effects of EMF could also be expressed as symptoms in the cardiovascular system. Other common effects of EMF include effects on skin, microvasculature, immune and hematologic systems. It is concluded that the mechanisms underlying the symptoms of EHS are biologically plausible and that many organic physiologic responses occur following EMF exposure. Patients can have neurologic, neuro-hormonal and neuro-psychiatric symptoms following exposure to EMF as a consequence of neural damage and over-sensitized neural responses. More relevant diagnostic tests for EHS should be developed. Exposure limits should be lowered to safeguard against biologic effects of EMF. Spread of local and global wireless networks should be decreased, and safer wired networks should be used instead of wireless, to protect susceptible members of the public. Public places should be made accessible for electrohypersensitive individuals.

Cancer in General Responders Participating in World Trade Center Health Programs, 2003-2013.

BACKGROUND: Following the September 11, 2001, attacks on the World Trade Center (WTC), thousands of workers were exposed to an array of toxins known to cause adverse health effects, including cancer. This study evaluates cancer incidence in the WTC Health Program General Responder Cohort occurring within 12 years post exposure. METHODS: The study population consisted of 28 729 members of the General Responder Cohort enrolled from cohort inception, July 2002 to December 31, 2013. Standardized incidence ratios (SIRs) were calculated with cancer case inclusion and follow-up starting post September 11, 2001 (unrestricted) and, alternatively, to account for selection bias, with case inclusion and follow-up starting 6 months after enrollment in the WTC Health Program (restricted). Case ascertainment was based on linkage with six state cancer registries. Under the restricted criterion, hazard ratios were estimated using multivariable Cox proportional hazards models for all cancer sites combined and for prostate cancer. RESULTS: Restricted analyses identified 1072 cancers in 999 responders, with elevations in cancer incidence for all cancer sites combined (SIR = 1.09, 95% confidence interval [CI] = 1.02 to 1.16), prostate cancer (SIR = 1.25, 95% CI = 1.11 to 1.40), thyroid cancer (SIR = 2.19, 95% CI = 1.71 to 2.75), and leukemia (SIR = 1.41, 95% CI = 1.01 to 1.92). Cancer incidence was not associated with any WTC exposure index (composite or individual) for all cancer sites combined or for prostate cancer. CONCLUSION: Our analyses show statistically significant elevations in cancer incidence for all cancer sites combined and for prostate and thyroid cancers and leukemia. Multivariable analyses show no association with magnitude or type of exposure.

The Burden of Subthreshold Posttraumatic Stress Disorder in World Trade Center Responders in the Second Decade After 9/11.

OBJECTIVE: To characterize the prevalence, risk and protective correlates, and clinical characteristics associated with probable subthreshold posttraumatic stress disorder (PTSD) in police and nontraditional (eg, construction workers) World Trade Center (WTC) responders a median of 12.2 years after September 11, 2001. METHODS: A total of 4,196 WTC responders, monitored via the WTC Health Program, completed a web-based survey between 2012 and 2014 assessing a range of variables, including demographics, WTC exposures, medical and psychiatric comorbidities, and mental health services use. The sample included 2,029 police responders and 2,167 nontraditional responders. Current (past-month) probable WTC-related PTSD level (none, subthreshold, or full PTSD) was assessed based on DSM-IV criteria using the PTSD Checklist-Specific Stressor version (PCL-S). RESULTS: The prevalence of current probable full and subthreshold WTC-related PTSD in police responders was 9.3% and 17.5%, respectively, and in nontraditional responders was 21.9% and 24.1%, respectively. Risk and protective correlates for subthreshold PTSD included post-9/11 medical comorbidities and traumatic events (odds ratios [ORs] = 1.1-1.2). Clinical characteristics included elevated rates of comorbid depression (OR = 3.2 and 3.9 for subthreshold PTSD and 17.2 and 30.3 for full PTSD for nontraditional and police responders, respectively). Among responders with subthreshold PTSD, police were more likely to have accessed mental health services and utilized a greater variety of treatments than nontraditional responders. CONCLUSIONS: Overall, 26.8% of police and 46.0% of nontraditional responders met criteria for probable WTC-related full or subthreshold PTSD an average of 12 years after 9/11. Probable subthreshold PTSD, which is not typically assessed in clinical settings, was more prevalent than probable full PTSD and was associated with significantly elevated rates of psychiatric comorbidities, functional impairment, and reduced quality of life. These findings underscore the importance of assessing, monitoring, and possibly treating subthreshold PTSD in WTC and other disaster responders.

Mental Healthcare Needs in World Trade Center Responders: Results from a Large, Population-Based Health Monitoring Cohort.

Nearly two decades after the 9/11 attacks on the World Trade Center (WTC), the prevalence of mental disorders remains elevated among traditional (e.g., police) and non-traditional (e.g., construction workers) responders who were involved in the WTC rescue, recovery, and clean-up efforts. To date, however, scarce research has examined factors associated with perceived need for mental health care, which is critical to promoting engagement in mental health treatment in this population. Data were analyzed from 16,170 WTC responders, including 8881 police responders and 7289 non-traditional responders, who completed their first annual health monitoring visit with the WTC Health Program an average of 6.5 years after September 11, 2001. Predisposing, enabling, and need-based factors associated with perceived need for mental health care were examined using multivariable logistic regression analyses. Nearly half (48.7%) of non-traditional responders and a fifth (20.6%) of police responders reported a need for mental health care. The most common perceived needs were for psychotropic medication, individual psychotherapy, and stress management counseling. Predisposing (e.g., female gender) and need-based factors (e.g., WTC-related posttraumatic stress disorder) predicted perceived need for mental health care in both groups. Among non-traditional responders, Hispanic ethnicity and current suicidal ideation were additionally associated with this outcome. Non-traditional WTC responders are substantially more likely than police WTC responders to perceive a need for mental health treatment. Characterization of factors associated with perceived need for treatment can help inform population-based outreach and monitoring efforts designed to promote engagement in mental health treatment in WTC responders.