Faculty Bibliography

Dust created by the collapse of the World Trade Center (WTC) towers on 9/11 included metals and toxicants that have been linked to an increased risk of pulmonary fibrosis (PF) in the literature. Little has been reported on PF among WTC responders. This report used self-reported physician diagnosis of PF with an unknown sub-type to explore the association between levels of WTC dust exposure and PF. We included 19,300 WTC responders, enrolled in the WTC Health Registry in 2003⁻2004, who were followed for 11 years from 2004 to 2015. Exposure was defined primarily by intensity and duration of exposure to WTC dust/debris and work on the debris pile. Stratified Cox regression was used to assess the association. We observed 73 self-reported physician-diagnosed PF cases, with a PF incidence rate of 36.7/100,000 person-years. The adjusted hazard ratio (AHR) of PF was higher in those with a medium (AHR = 2.5, 95% CI = 1.1⁻5.8) and very high level of exposure (AHR = 4.5, 95% CI = 2.0⁻10.4), compared to those with low exposure. A test for exposure-response trend was statistically significant (P_trend = 0.004). Future research on WTC dust exposure and PF would benefit from using data from multiple WTC Health Program responder cohorts for increased statistical power and clinically confirmed cases.

Thousands of lower Manhattan residents sustained damage to their homes following the collapse of the Twin Towers on 11 September 2001. Respiratory outcomes have been reported in this population. We sought to describe patterns of home damage and cleaning practices in lower Manhattan and their impacts on respiratory outcomes among World Trade Center Health Registry (WTCHR) respondents. Data were derived from WTCHR Wave 1 (W1) (9/2003⁻11/2004) and Wave 2 (W2) (11/2006⁻12/2007) surveys. Outcomes of interest were respiratory symptoms (shortness of breath (SoB), wheezing, persistent chronic cough, upper respiratory symptoms (URS)) first occurring or worsening after 9/11 W1 and still present at W2 and respiratory diseases (asthma and chronic obstructive pulmonary disease (COPD)) first diagnosed after 9/11 W1 and present at W2. We performed descriptive statistics, multivariate logistic regression and geospatial analyses, controlling for demographics and other exposure variables. A total of 6447 residents were included. Mean age on 9/11 was 45.1 years (±15.1 years), 42% were male, 45% had ever smoked cigarettes, and 44% reported some or intense dust cloud exposure on 9/11. The presence of debris was associated with chronic cough (adjusted OR (aOR) = 1.56, CI: 1.12⁻2.17), and upper respiratory symptoms (aOR = 1.56, CI: 1.24⁻1.95). A heavy coating of dust was associated with increased shortness of breath (aOR = 1.65, CI: 1.24⁻2.18), wheezing (aOR = 1.43, CI: 1.03⁻1.97), and chronic cough (aOR = 1.59, CI: 1.09⁻2.28). Dusting or sweeping without water was the cleaning behavior associated with the largest number of respiratory outcomes, such as shortness of breath, wheezing, and URS. Lower Manhattan residents who suffered home damage following the 9/11 attacks were more likely to report respiratory symptoms and diseases compared to those who did not report home damage.

BACKGROUND:Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. METHODS:We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. RESULTS:In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. CONCLUSIONS:Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

OBJECTIVE:Following the World Trade Center (WTC) terrorist attack in New York City, prevalence rates of posttraumatic stress disorder (PTSD) and depression remain elevated. Although social support and self-efficacy have been associated with PTSD, little is known about their differential effect on PTSD and depressive comorbidity. METHOD/METHODS:= 1,304) were assessed at Wave 1 (2003-2004), Wave 2 (2006-2007), Wave 3 (2011-2012), and Wave 4 (2015-2016). RESULTS:= 0.76). CONCLUSIONS:Findings indicate that self-efficacy may be more important to the severity and chronicity of PTSD symptoms than social support. Multivariate comparisons suggest that PTSD with comorbid depression is a presentation of trauma-dependent psychopathologies, as opposed to depression alone following trauma, which was independent of trauma exposure and may be secondary to the traumatic event and posttraumatic response. Implications for assessment and treatment are discussed. (PsycINFO Database Record

To compare the prevalence of mammography and prostate-specific antigen (PSA) testing in 9/11-exposed persons with the prevalence among the US population, and examine the association between 9/11 exposures and these screening tests using data from the World Trade Center Health Registry (WTCHR) cohort. We studied 8190 female and 13,440 male enrollees aged ≥40 years at survey completion (2015-2016), who had a medical visit during the preceding year, had no self-reported breast or prostate cancer, and did not have screening for non-routine purposes. We computed age-specific prevalence of mammography (among women) and PSA testing (among men), and compared to the general population using 2015 National Health Interview Survey data (NHIS). We also computed the adjusted prevalence ratio (PR) and 95% confidence interval (95% CI) to examine the relationship between 9/11 exposures and screening uptakes using modified Poisson regression. Our enrollees had higher prevalences of mammogram and PSA testing than the US general population. 9/11 exposure was not associated with mammography uptake. Proximity to the WTC at the time of the attacks was associated with PSA testing in the age 60-74 group (PR = 1.06; 95% CI = 1.00-1.12). Among rescue/recovery workers and volunteers (RRW), being a firefighter was associated with higher PSA testing than other RRW across all age groups (40-49: PR = 1.45, 95% CI 1.16-1.81; 50-59: PR = 1.33, 95% CI 1.22-1.44; 60-74: PR = 1.14, 95% CI 1.06-1.23). Screening activities should be considered when studying cancer incidence and mortality in 9/11 exposed populations.

AIM/OBJECTIVE:There is limited information regarding asthma triggers in World Trade Center (WTC) rescue and recovery workers (RRW) or how mental health conditions affect the perception of triggers. METHODS:We included 372 WTC workers with asthma. The Asthma Trigger Inventory (ATI) assessed triggers along five domains: psychological, allergens, physical activity, infection, and pollution. We administered the Structured Clinical Interview to diagnose post-traumatic stress disorder (PTSD), major depression and panic disorder (PD). The Asthma Control Questionnaire (ACQ) and Mini Asthma Quality of Life Questionnaire (AQLQ) measured asthma control and quality of life, respectively. Linear regression models were fitted to examine the association of ATI total and subdomain scores with mental health conditions as well as the percent of ACQ and AQLQ variance explained by ATI subscales. RESULTS:=0.14, p = 0.64) scores. CONCLUSION/CONCLUSIONS:RRW with mental health conditions reported more asthma triggers and these triggers were associated with asthma morbidity. These data can help support interventions in RRW with asthma.

BACKGROUND:Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. MATERIALS AND METHODS/METHODS:Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. RESULTS:We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. CONCLUSIONS:Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

OBJECTIVE: We described the patterns of asthma hospitalization among persons exposed to the 2001 World Trade Center (WTC) attacks, and assessed whether 9/11-related exposures or comorbidities, including posttraumatic stress disorder (PTSD) and gastroesophageal reflux symptoms (GERS), were associated with an increased rate of hospitalization. METHODS: Data for adult enrollees in the WTC Health Registry, a prospective cohort study, with self-reported physician-diagnosed asthma who resided in New York State on 9/11 were linked to administrative hospitalization data to identify asthma hospitalizations during September 11, 2001-December 31, 2010. Multivariable zero-inflated Poisson regression was used to examine associations among 9/11 exposures, comorbid conditions, and asthma hospitalizations. RESULTS: Of 11 471 enrollees with asthma, 406 (3.5%) had >/=1 asthma hospitalization during the study period (721 total hospitalizations). Among enrollees diagnosed before 9/11 (n = 6319), those with PTSD or GERS had over twice the rate of hospitalization (adjusted rate ratio (ARR) = 2.5, 95% CI = 1.4-4.1; ARR = 2.1, 95% CI = 1.3-3.2, respectively) compared to those without. This association was not statistically significant in enrollees diagnosed after 9/11. Compared to higher educational attainment, completing less than college was associated with an increased hospitalization rate among participants with both pre-9/11- and post-9/11-onset asthma (ARR = 1.9, 95% CI = 1.2-2.9; ARR = 2.6, 95% CI = 1.6-4.1, respectively). Sinus symptoms, exposure to the dust cloud, and having been a WTC responder were not associated with asthma hospitalization. CONCLUSIONS: Among enrollees with pre-9/11 asthma, comorbid PTSD and GERS were associated with an increase in asthma hospitalizations. Management of these comorbidities may be an important factor in preventing hospitalization.

PURPOSE/OBJECTIVE:The present study aims to examine the impact of physical and mental health comorbidities on the association between post-9/11 posttraumatic stress disorder (PTSD) trajectories over 10 years and health-related quality of life (HRQOL) among 9/11-exposed persons. METHODS:30,002 responding adult World Trade Center Health Registry enrollees reporting no pre-9/11 PTSD were studied. PTSD trajectories (chronic, delayed, remitted, no PTSD) were defined based on a 17-item PTSD Checklist-Specific to 9/11 across three waves of survey data. Three indicators of poor HRQOL were defined based on CDC HRQOL-4 measures. We computed age-adjusted prevalence of physical and mental health comorbidity (depression/anxiety) by PTSD trajectory and used modified Poisson regression to assess the effect of PTSD trajectory on poor HRQOL prevalence, accounting for comorbidity. RESULTS:Age-adjusted prevalence of overall comorbid conditions was 95.8 and 61.4% among the chronic and no-PTSD groups, respectively. Associations between 9/11-related PTSD trajectories and poor HRQOL were significant and became greater when comorbidity was included. Adjusted prevalence ratios were elevated for fair/poor health status (APR 7.3, 95% CI 6.5, 8.2), ≥ 14 unhealthy days (4.7; 95% CI 4.4, 5.1), and ≥ 14 activity limitation days during the last 30 days (9.6; 95% CI 8.1, 11.4) in the chronic PTSD group with physical and mental health comorbidity compared to those without PTSD and comorbidity; similar associations were observed for delayed PTSD. CONCLUSIONS:Ten years post-9/11 physical and mental health comorbidities have a substantial impact on the PTSD trajectories and HRQOL association. The need for early identification and treatment of PTSD and comorbidity should be emphasized to potentially improve HRQOL.

Ten to eleven years after the September 11, 2001 terrorist attacks, probable posttraumatic stress disorder (PTSD) was evaluated in 1,755 World Trade Center (WTC) evacuees based on data from the WTC Health Registry. Characteristics of men and women were compared and factors associated with PTSD symptom severity were examined using the PTSD Checklist (PCL). Compared with men (n = 1,015, 57.8%), women (n = 740, 42.2%) were younger and of lower socioeconomic status. Ten to eleven years after September 11, 2001, 13.7% of men and 24.1% of women met criteria for PTSD. Results indicated that when considered with all other variables (i.e., demographic, socioeconomic and social resources, exposure to the attacks, life events), gender was not a significant predictor of PTSD symptom severity. Being younger on September 11, 2001, unemployed, less educated, and/or having higher exposure to the attacks, unmet mental health care needs, and less social support predicted higher PCL scores for both genders (βs = .077 to .239). Demographic characteristics and socioeconomic resources (ΔR² = .113) accounted for the largest amount of variance in PCL scores over and above exposure/evacuation, mental healthcare needs, and social support variables (ΔR² = .093 to .102). When trends of unmet mental healthcare needs were analyzed, the most prevalent response for men was that they preferred to manage their own symptoms (15.1%), whereas the most prevalent response for women was that they could not afford to pay for mental health care (14.7%). Although the prevalence of probable PTSD in women tower survivors was approximately twice as high as it was for men, this is attributable largely to demographic and socioeconomic resource factors and not gender alone. Implications for treatment and interventions are discussed.