FE NO concentrations in World Trade Center responders and controls, 6 years post-9/11.

The aim of this study was to evaluate whether underlying respiratory disease may be revealed by offline fractional exhaled nitric oxide (FE(NO)) testing among a cohort of New York State (NYS) World Trade Center (WTC) responders in comparison with a control group of similar but unexposed NYS employees, 6 years post-9/11. Participants (92 exposed, 141 unexposed) provided two breath samples that were collected in Mylar bags and sent to a central laboratory for FE(NO) testing. Participants also completed a brief questionnaire. Ambient air pollution was characterized using particulate matter (PM(2.5)) and ozone concentration data from the NYS Department of Environmental Conservation air-monitoring sites closest to each testing site for each day of sample collection. WTC exposure did not appear to be associated with elevated FE(NO) concentrations. FE(NO) concentrations were higher on days with elevated levels of PM(2.5) (≥ 35 µg/m³) and ozone (≥ 0.08 ppm). FE(NO) concentrations were higher in men and lower in smokers. Our results do not suggest an association between WTC exposure and elevated FE(NO) concentrations, 6 years post-9/11, in this moderately exposed cohort of responders. Results do suggest that FE(NO) concentrations were elevated in relation to higher levels of ambient air pollutants. Our results also offer useful reference values for future research involving FE(NO) testing. This study demonstrates that offline FE(NO) testing is a useful method for epidemiological studies requiring collection of samples in the field, potentially over a broad geographic area.

A nested case-control study of low birthweight among cosmetologists.

OBJECTIVE: This study was designed to determine whether licensed female cosmetologists with a low birthweight child were more likely to perform specific occupational tasks during pregnancy than cosmetologists who had a normal weight child. We also investigated certain salon characteristics in relation to low birthweight status. METHODS: This nested case-control study followed-up a positive association of low birthweight children among cosmetologists found in a retrospective cohort study previously reported. Cases were cosmetologists with children born between 1997 and 2003 weighing <2,500 g, selected from the retrospective cohort study. Controls were cosmetologists with full-term children who weighed >2,500 grams at birth, frequency matched on year of birth of the child. A mailed questionnaire gathered information on potential confounders and detailed exposure information about work environment and occupational tasks of cosmetologists. Frequency of product use was dichotomized into daily/less than daily for each task. Number of hours worked per week was also considered. Birth certificate data were used for information on some potential confounders and birthweight. Using logistic regression, adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were obtained. RESULTS: A total of 125 (30%) cases and 158 (35%) controls agreed to participate. Responders and non-responders were similar on birthweight and most demographic characteristics. None of the specific cosmetology tasks studied were associated with low birthweight. Working in a salon located in a house/building with other businesses was associated with having a low birthweight child [OR = 2.20, 95% CI (1.21, 4.02)]. CONCLUSIONS: We did not find any associations between specific tasks of cosmetologists and low birthweight.

Impulse oscillometry and respiratory symptoms in World Trade Center responders, 6 years post-9/11.

This study evaluated whether impulse oscillometry (IOS) testing revealed signs of respiratory disease in New York State (NYS) World Trade Center (WTC) responders in comparison with unexposed NYS employees. It also compared self-reported respiratory symptoms between the two groups, 6 years post-9/11. For this evaluation participants completed a self-administered questionnaire regarding respiratory symptoms. IOS testing included measures of resistance and reactance to assess for peripheral versus central airway effects. Two hundred forty-eight subjects (99 exposed and 149 unexposed) were included in the final analysis. Since September 11, 2001, NYS responders were more likely to report new or worsening cough in the absence of a respiratory infection, cough consistent with chronic bronchitis, current respiratory symptoms, or lower respiratory symptoms in the last 12 months. Significant associations were found between IOS indices and gender, smoking history, and obesity. When comparing exposed and unexposed participants, there were no significant differences in the geometric means of the IOS indices. Responders who used a respirator with canister demonstrated significantly lower respiratory resistance at 5 and 20 Hz (R5 and R20). While this study has provided no evidence of an association between WTC exposure and peripheral airways disease in this cohort of responders, results do suggest that use of a respirator with canister may be protective for central airways in responders exposed to dust and smoke. This emphasizes the importance of stressing proper respirator use in planning responses to future disasters. Our control data also provide useful reference values for future IOS research.

Asthma and lower respiratory symptoms in New York State employees who responded to the World Trade Center disaster.

PURPOSE: To investigate whether New York State employees who responded to the World Trade Center disaster were more likely to report asthma or lower respiratory symptoms (LRS; cough, wheeze, chest tightness, shortness of breath) than non-exposed employees, 2 years post-September 11. METHODS: Participants (578 exposed, 702 non-exposed) completed mailed questionnaires in 2003. A unique exposure assessment method was used; exposure scores were divided at the mean (at/below, above). Poisson regression was used. RESULTS: Exposure was associated with LRS, but not asthma. Participants with exposure scores at/below the mean had a twofold increased risk of most LRS. Those with scores above the mean had a three to fourfold increased risk. For scores above the mean, the magnitude of effect was consistently higher for smoke exposure. CONCLUSIONS: Moderately exposed responders may experience health impacts from exposures in later stages of a disaster. Exposure to smoke may have had a greater lower respiratory impact than resuspended dust.

Long-term respiratory symptoms in World Trade Center responders.

BACKGROUND: New York State (NYS) employees who responded to the World Trade Center (WTC) disaster on or after 11 September 2001 potentially experienced exposures that might have caused persistent respiratory effects. NYS responders represent a more moderately exposed population than typical first responders. AIMS: To assess whether NYS employees who were WTC responders were more likely than controls to report lower respiratory symptoms (LRS) or a diagnosis of asthma 5 years post-9/11. Persistence and severity of symptoms were also evaluated. METHODS: Participants were initially mailed self-administered questionnaires (initial, Year 1, Year 2) and then completed a telephone interview in Year 3. Data were analysed using Poisson's regression models. RESULTS: WTC exposure was associated with LRS, including cough symptoms suggestive of chronic bronchitis, 5 years post-9/11. When exposure was characterized using an exposure assessment method, the magnitude of effect was greater in those with exposure scores above the mean. WTC exposure was associated with persistence of LRS over the 3 year study period. Results also suggest that participants with the highest exposures were more likely to experience increased severity of their asthma condition and/or LRS. CONCLUSIONS: Our findings suggest that even in a moderately exposed responder population, lower respiratory effects were a persistent problem 5 years post-9/11, indicating that some WTC responders require ongoing monitoring.

The risk of congenital malformations and other neonatal and maternal health outcomes among licensed cosmetologists.

This study sought to determine if cosmetologists in New York State (NYS) have a higher risk of complications of labor/delivery or congenital malformations and poor neonatal health indicators among their offspring compared with Realtors and the general population. This retrospective cohort study matched licensing records for cosmetologists and realtors to birth records and the NYS Congenital Malformations Registry from 1997 to 2003. A random sample of NYS birth certificates, frequency matched to cosmetologists on year of child's birth, mother's ethnicity, and education, was also formed. Outcomes include malformations of each major organ system, neonatal health indicators, and complications of labor/delivery. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), controlling for potential confounders. Compared with Realtors, cosmetologists had an increased risk of several maternal and neonatal health indicators, including postpartum hemorrhage (OR = 2.12; 95% CI 1.26, 3.58), failure to progress (OR = 1.31; 95% CI 1.12, 1.54), and newborn intubation (OR = 2.34; 95% CI 1.21, 4.51), among others. We did not observe an increased risk of congenital malformations among cosmetologists' offspring. Working as a cosmetologist was positively associated with several adverse maternal perinatal and neonatal health indicators but was not associated with congenital malformations in this study. These results are useful for hypothesis generating.

Development of an exposure assessment method for epidemiological studies of New York State personnel who responded to the World Trade Center disaster.

OBJECTIVES: An exposure assessment method was developed for use in assigning an exposure score to New York State personnel who responded to the World Trade Center disaster site after the 11 September 2001 terrorist attacks. METHODS: The method consists of an algorithm with two instantiations. Each represents a major component of the overall exposures at the site: dust and smoke. The algorithm uses US Environmental Protection Agency air monitoring data collected between 23 September 2001 and 28 February 2002, as well as information on duration, location and time period of work assignment and type and frequency of personal protective respiratory equipment (PPE) use, collected by a self-administered mailed questionnaire. These data were used to calculate an overall exposure score for each participant. For each time period/location combination, individuals provided average number of hours and number of days worked. This was multiplied by a weighting factor derived from the median of the air monitoring data for the time period/location. Calcium was chosen as a surrogate for the dust exposure, so the weighting factors for the dust instantiation were calculated from calcium air monitoring data. Total hepta-chlorinated dibenzo-p-dioxin was chosen as a surrogate for the smoke exposure and was similarly used in the smoke instantiation. RESULTS: More individuals in the highest exposure score category performed tasks such as search/rescue and hand digging than those in the lowest exposure category. Also, those in the highest exposure category had a higher mean number of hours at the site than other exposure groups. CONCLUSIONS: The exposure assessment method presented accounts for PPE use, amount of time at the site, proximity to the site and ambient air monitoring results taken in the immediate vicinity. The algorithm can be used to rank individuals in the same study with very different patterns of exposure, such as high-level, short-term exposures and low-level, long-term exposures. The concepts could be modified for use in other epidemiological studies where long-term chronic exposure is a concern.

Health effects in New York State personnel who responded to the World Trade Center disaster.

OBJECTIVE: To conduct an evaluation of health effects in New York State personnel who responded to the World Trade Center disaster. METHODS: Data from a medical monitoring program, including questionnaire data, physical examination results, and clinical and laboratory test results were evaluated for 1423 participants. Descriptive statistics were reviewed and data were analyzed using logistic regression. RESULTS: Lower and upper respiratory symptoms were reported by nearly half of the study participants. One third reported a psychological symptom. Some health effects, including respiratory symptoms and symptoms suggestive of posttraumatic stress disorder, were associated with having been caught in the cloud of dust on September 11, 2001. CONCLUSIONS: This cohort probably experienced less overall exposure than other World Trade Center responder cohorts did. Results suggest that being present when the buildings collapsed was associated with reported symptoms.

An evaluation of a Lyme disease prevention program in a working population.

PURPOSE: Lyme disease vaccine was offered to New York State Department of Health employees considered at risk for Lyme disease because of their job duties. This evaluation was conducted to assess (1) attitudes that affected employees' decisions to accept or decline the vaccine, (2) preventive behaviors among employees who received the vaccine, and (3) effectiveness of the educational modalities offered in improving knowledge of Lyme disease and Lyme disease vaccine. METHODS: A total of 190 eligible employees were identified and were offered two educational modalities before deciding whether to receive the vaccine. The subsequent evaluation involved three telephone interviews, one pre-education and two posteducation-vaccination, to assess factors affecting the decision about vaccination and attitudes, behaviors, and knowledge among vaccine recipients (N=30) and nonrecipients (N=160). RESULTS: This evaluation indicated that the majority of vaccine recipients decided to receive the vaccine because of an anticipated risk of tick exposure. For employees who declined vaccination, many were concerned about the safety (64%), novelty (56%), or efficacy (48%) of the vaccine. Posteducation knowledge of Lyme disease vaccine significantly improved among those who attended an education session compared with those who did not and was retained 1 year later. DISCUSSION: The results suggest that when a vaccine-related disease-prevention program is undertaken, (1) attitudes about disease risks and vaccine risks influence decisions to accept vaccination, and (2) in-person education should be a mandatory element of the program.

The role of epidemiology in disaster response policy development.

PURPOSE: Disasters expose the general population and responders to a range of potential contaminants and stressors which may harm physical and mental health. This article addresses the role of epidemiology in informing policies after a disaster to mitigate ongoing exposures, provide care and compensation, and improve preparedness for future disasters. METHODS: The World Trade Center disaster response is used as a case study. We examine how epidemiologic evidence was used to shape postdisaster policy and identify important gaps in early research. RESULTS: In the wake of World Trade Center attacks, epidemiologic research played a key role in identifying and characterizing affected populations, assessing environmental exposures, quantifying physical and mental health impacts, and producing evidence to ascribe causation. However, most studies suffered from methodological challenges, including delays, selection biases, poor exposure measurement, and nonstandardized outcomes. Gaps included measuring unmet health needs and financing coverage, as well as coordination across longitudinal cohorts of studies for rare conditions with long latency, such as cancer. CONCLUSIONS: Epidemiologists can increase their impact on evidence-based policymaking by ensuring core mechanisms are in place before a disaster to mount monitoring of responders and other affected populations, improve early exposure assessment efforts, identify critical gaps in scientific knowledge, and coordinate communication of scientific findings to policymakers and the public.

Lessons learned from the september 11th disaster: a state health agency perspective.

The New York State Department of Health has conducted a number of studies over the past 10 years investigating health impacts related to the September 11, 2001 (9/11) disaster among New York City residents and New York State World Trade Center (WTC) responders. Efforts to evaluate the health effects of WTC exposures in these cohorts presented numerous challenges, including study design and associated concerns about bias, identifying the affected populations, gaining community support and participation, and determining the most appropriate clinical testing and follow-up approaches. The unique position of a state public health agency provided multiple points of support for these efforts. An overview of what was found and the lessons learned during the response to the 9/11 disaster is presented, from the viewpoint of a state public health agency.

Polychlorinated dibenzo-p-dioxins, dibenzofurans, biphenyls, and naphthalenes in plasma of workers deployed at the World Trade Center after the collapse.

Blood plasma samples (n = 43) collected retrospectively from New York State employees and National Guard personnel who had been assigned to work in the vicinity of the World Trade Center (WTC) during the week after the collapse of the buildings were analyzed for polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), polychlorinated biphenyls (PCBs), and polychlorinated naphthalenes (PCNs). On the basis of algorithms developed to rank individual exposures to dust and debris and to smoke, we categorized the samples as: more smoke exposure (MSE), more dust exposure (MDE), less smoke exposure (LSE), and less dust exposure (LDE). Mean concentrations of PCDDs were 1070, 223, 3690, and 732 pg/g lipid wt, and mean concentrations of PCDFs were 910, 1520, 230, and 117 pg/g lipid wt, for the MSE, MDE, LSE, and LDE groups, respectively. The concentrations of PCDFs were higher in the two "more exposure" groups than in the two "less exposure" groups. Calculated TEQ concentrations of coplanar PCBs and PCDD/Fs in plasma samples were, on average, 1.12 and 41.2 pg WHO-TEQ/g lipid wt, respectively. TEQ concentrations of PCDFs were higher than those of PCDDs in both "more exposure" groups but lower than those of PCDDs in "less exposure" groups. This result is suggestive of exposure of the WTC responders to PCDFs after the WTC collapse. PCDFs contributed the majority of TEQs and are therefore the critical dioxin-like compounds in MSE/MDE groups, whereas PCDDs are the critical compounds in the LSE/LDE groups.

The risk of having a low birth weight or preterm infant among cosmetologists in New York State.

OBJECTIVES: This study sought to determine if female licensed cosmetologists have a higher risk of low birth weight, small-for-gestational-age, and preterm delivery compared to two different comparison groups. METHODS: This retrospective cohort study matched 15,003 licensed cosmetologists and a comparison group of 4,246 licensed realtors to birth records in New York State from 1997 to 2003. A second comparison group from the general population of New York State (n = 12,171) was frequency matched to cosmetologists on child's year of birth, mother's ethnicity and mother's education. RESULTS: A positive association was found for low birth weight when comparing cosmetologists to realtors (adjusted odds ratio 1.36 (95% confidence interval: 1.09, 1.70)). Associations were stronger in non-whites than in whites in each birth weight comparison. Associations observed for small-for-gestational-age or preterm births with either comparison group were close to the null or had wide confidence intervals that included the null. CONCLUSIONS: We observed a slightly increased risk for having a child born low birth weight among cosmetologists compared to another group of licensed professionals. The risk was greater among non-white races in each comparison.

Biomonitoring of perfluorochemicals in plasma of New York State personnel responding to the World Trade Center disaster.

The collapse of the World Trade Center (WTC) on September 11, 2001 resulted in the release of several airborne pollutants in and around the site. Perfluorochemicals including perfluorooctanesulfonate (PFOS) and perfluorooctanoic acid (PFOA), which are used in soil- and stain-resistant coatings on upholstery, carpets, leather, floor waxes, polishes, and in fire-fighting foams were potentially released during the collapse of the WTC. In this pilot study, we analyzed 458 plasma samples of New York State (NYS) employees and National Guard personnel assigned to work in the vicinity of the WTC between September 11 and December 23, 2001, to assess exposure to perfluorochemicals released in dust and smoke. The plasma samples collected from NYS WTC responders were grouped based on estimated levels of exposure to dust and smoke, as follows: more dust exposure (MDE), less dust exposure (LDE), more smoke exposure (MSE), and less smoke exposure (LSE). Furthermore, samples were grouped, based on self-reported symptoms at the time of sampling, as symptomatic and asymptomatic. Eight perfluorochemicals were measured in 458 plasma samples. PFOS, PFOA, perfluorohexanesulfonate (PFHxS), and perfluorononanoic acid (PFNA), were consistently detected in almost all samples. PFOA and PFHxS concentrations were approximately 2-fold higher in WTC responders than the concentrations reported for the U.S. general population. No significant difference was observed in the concentrations of perfluorochemicals between symptomatic and asymptomatic groups. Concentrations of PFHxS were significantly (p < or = 0.05) higher in the MDE group than in the LDE group. Concentrations of PFNA were significantly higher in the MSE group than in the LSE group. Significantly higher concentrations of PFOA and PFHxS were found in individuals exposed to smoke than in individuals exposed to dust. A significant negative correlation existed between plasma lipid content and concentrations of certain perfluorochemicals. Our initial findings suggest that WTC responders were exposed to perfluorochemicals, especially PFOA, PFNA, and PFHxS, through inhalation of dust and smoke released during and after the collapse of the WTC. The potential health implications of these results are unknown at this time. Expansion of testing to include all archived samples will be critical to help confirm these findings. In doing so, it may be possible to identify biological markers of WTC exposure and to improve our understanding of the health impacts of these compounds.