Faculty Bibliography

OBJECTIVES: Excess gastroesophageal reflux disease (GERD) was reported in several populations exposed to the September 11 2001 (9/11) terrorist attacks on the World Trade Center (WTC). We examined new onset gastroesophageal reflux symptoms (GERS) since 9/11 and persisting up to 5-6 years in relation to 9/11-related exposures among the WTC Health Registry enrollees, and potential associations with comorbid asthma and posttraumatic stress disorder (PTSD). METHODS: This is a retrospective analysis of 37,118 adult enrollees (i.e., rescue/recovery workers, local residents, area workers, and passersby in lower Manhattan on 9/11) who reported no pre-9/11 GERS and who participated in two Registry surveys 2-3 and 5-6 years after 9/11. Post-9/11 GERS (new onset since 9/11) reported at first survey, and persistent GERS (post-9/11 GERS reported at both surveys) were analyzed using log-binomial regression. RESULTS: Cumulative incidence was 20% for post-9/11 GERS and 13% for persistent GERS. Persistent GERS occurred more often among those with comorbid PTSD (24%), asthma (13%), or both (36%) compared with neither of the comorbid conditions (8%). Among enrollees with neither asthma nor PTSD, the adjusted risk ratio (aRR) for persistent GERS was elevated among: workers arriving at the WTC pile on 9/11 (aRR=1.6; 95% confidence interval (CI) 1.3-2.1) or working at the WTC site > 90 days (aRR=1.6; 1.4-2.0); residents exposed to the intense dust cloud on 9/11 (aRR=1.5; 1.0-2.3), or who did not evacuate their homes (aRR=1.7; 1.2-2.3); and area workers exposed to the intense dust cloud (aRR=1.5; 1.2-1.8). CONCLUSIONS: Disaster-related environmental exposures may contribute to the development of GERS. GERS may be accentuated in the presence of asthma or PTSD.

OBJECTIVES: This retrospective study analyzed a primary care depression screening initiative in a large urban university health center. Depression detection, treatment status, and engagement data are presented. PARTICIPANTS: Participants were 3,713 graduate and undergraduate students who presented consecutively for primary care services between January and April 2006. METHODS: A standardized 2-tiered screening approach for an inception cohort of students utilizing primary services. Primary care providers were trained to triage students with depressive symptoms. RESULTS: Six percent of participants had clinically significant depressive symptoms (CSD). Severe depressive symptoms were found in less than 1.0% of participants. Male rates of severe depressive symptoms were more than double that of females. Only 35.7% of untreated depressed participants started treatment within 30 days following identification. CONCLUSIONS: Systematic primary care depression screening in a college health center is a promising approach to identify untreated students with depression. More study is needed to improve rates of treatment engagement.

OBJECTIVE: To describe the development of and some of the early results from the World Trade Center Health Registry (WTCHR). Is the WTCHR a model for a nanomaterials exposure registry? What lessons may be learned from the WTCHR? METHODS: We describe the steps involved in creation of the WTCHR, from design through implementation. RESULTS: The lessons learned from the WTCHR include thorough documentation of exposure early in the registry, using multimode surveys to maximize response rate, establishing an institutional home with sufficient resources for core as well as in-depth longitudinal and intervention studies, meeting with stakeholders regularly, making data accessible, and timely publication of findings, including wide dissemination of clinical guidelines. CONCLUSIONS: The process of creating and maintaining the WTCHR provides important lessons for the possible creation of a nanomaterials exposure registry.

OBJECTIVE: To examine associations between 9/11-related exposures, posttraumatic stress disorder (PTSD), and subsequent development of heart disease (HD). METHODS: We prospectively followed 39,324 WTC Health Registry participants aged >/=18 on 9/11 for an average of 2.9 years. HD was defined as self-reported physician-diagnosed angina, heart attack, and/or other HD reported between study enrollment (2003-2004) and a follow-up survey (2006-2008) in enrollees without previous HD. A PTSD Checklist (PCL) score >/=44 was considered PTSD. We calculated adjusted hazard ratios (AHR) and 95% confidence intervals (CI) to examine relationships between 9/11-related exposures and HD. RESULTS: We identified 1162 HD cases (381 women, 781 men). In women, intense dust cloud exposure was significantly associated with HD (AHR 1.28, 95% CI 1.02-1.61). Injury on 9/11 was significantly associated with HD in women (AHR 1.46, 95% CI 1.19-1.79) and in men (AHR 1.33, 95% CI 1.15-1.53). Participants with PTSD at enrollment had an elevated HD risk (AHR 1.68, 95% CI 1.33-2.12 in women, AHR 1.62, 95% CI 1.34-1.96 in men). A dose-response relationship was observed between PCL score and HD risk. CONCLUSION: This exploratory study suggests that exposure to the WTC dust cloud, injury on 9/11 and 9/11-related PTSD may be risk factors for HD.

BACKGROUND: Serious respiratory illnesses have been reported among rescue/recovery workers (RRW) following the World Trade Center (WTC) attacks. METHODS: We studied RRW enrolled in the WTC Health Registry to assess the effects of different respiratory protection equipment (RPE) types on respiratory outcomes, such as recurrent respiratory symptoms and diseases possibly associated with 9/11 exposures. We performed descriptive and multivariate analyses adjusting for demographics and exposure variables. RESULTS: A total of 9,296 RRW met inclusion criteria. The strongest predictors of using adequate RPE were being affiliated with construction, utilities or environmental remediation organizations and having received RPE training. Workers who used respirators were less likely to report adverse respiratory outcomes compared to those who reported no/lower levels of respiratory protection. CONCLUSIONS: Level of respiratory protection was associated with the odds of reporting respiratory symptoms and diseases. Training, selection, fit testing, and consistent use of RPE should be emphasized among emergency responders.

BACKGROUND: The Sept 11, 2001 (9/11) World Trade Center (WTC) disaster has been associated with several subacute and chronic health effects, but whether excess mortality after 9/11 has occurred is unknown. We tested whether excess mortality has occurred in people exposed to the WTC disaster. METHODS: In this observational cohort study, deaths occurring in 2003-09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. Eligible participants were rescue and recovery workers and volunteers; lower Manhattan area residents, workers, school staff and students; and commuters and passers-by on 9/11. Study participants were categorised as rescue and recovery workers (including volunteers), or non-rescue and non-recovery participants. Standardised mortality ratios (SMR) were calculated with New York City rates from 2000-09 as the reference. Within the cohort, proportional hazards were used to examine the relation between a three-tiered WTC-related exposure level (high, intermediate, or low) and total mortality. FINDINGS: We identified 156 deaths in 13,337 rescue and recovery workers and 634 deaths in 28,593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0.45, 95% CI 0.38-0.53) and non-rescue and non-recovery participants (0.61, 0.56-0.66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1.22, 95% CI 1.01-1.48, for intermediate exposure and 1.56, 1.15-2.12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart-disease-related mortality (adjusted hazard ratio 2.06, 1.10-3.86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1.25, 95% CI 0.56-2.78, for high exposure and 1.03, 0.52-2.06, for intermediate exposure when compared with low exposure). INTERPRETATION: This exploratory study of mortality in a well defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants. FUNDING: US Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health, Agency for Toxic Substances and Disease Registry, and National Center for Environmental Health); New York City Department of Health and Mental Hygiene.

BACKGROUND: Volunteers (non-professional rescue/recovery workers) are universally present at man-made and natural disasters and share experiences and exposures with victims. Little is known of their disaster-related health outcomes. METHODS: We studied 4974 adult volunteers who completed the World Trade Center Health Registry 2006-07 survey to examine associations between volunteer type (affiliated vs. lay) and probable posttraumatic stress disorder (PTSD); new or worsening respiratory symptoms; post-9/11 first diagnosis of anxiety disorder, depression, and/or PTSD; and asthma or reactive airway dysfunction syndrome (RADS). Affiliated volunteers reported membership in a recognized organization. Lay volunteers reported no organizational affiliation and occupations unrelated to rescue/recovery work. Adjusted odds ratios (OR(adj)) were calculated using multinomial regression. RESULTS: Lay volunteers were more likely than affiliated volunteers to have been present in lower Manhattan, experience the dust cloud, horrific events and injury on 9/11 and subsequently to report unmet healthcare needs. They had greater odds of early post-9/11 mental health diagnosis (OR(adj) 1.6; 95% CI: 1.4-2.0) and asthma/RADS (1.8; 1.2-2.7), chronic PTSD (2.2; 1.7-2.8), late-onset PTSD (1.9; 1.5-2.5), and new or worsening lower respiratory symptoms (2.0; 1.8-2.4). CONCLUSIONS: Lay volunteers' poorer health outcomes reflect earlier, more intense exposure to and lack of protection from physical and psychological hazards. There is a need to limit volunteers' exposures during and after disasters, as well as to provide timely screening and health care post-disaster.

OBJECTIVE: Explore relationships between World Trade Center (WTC) exposures and sarcoidosis. METHODS: Sarcoidosis has been reported after exposure to the WTC disaster. We ascertained biopsy-proven post-9/11 sarcoidosis among WTC Health Registry enrollees. Cases diagnosed after Registry enrollment were included in a nested case-control study. Controls were matched to cases on age, sex, race or ethnicity, and eligibility group (eg, rescue or recovery worker). RESULTS: We identified 43 cases of post-9/11 sarcoidosis. Twenty-eight incident cases and 109 controls were included in the case-control analysis. Working on the WTC debris pile was associated with sarcoidosis (odds ratio 9.1, 95% confidence interval 1.1 to 74.0), but WTC dust cloud exposure was not (odds ratio 1.0, 95% confidence interval 0.4 to 2.8). CONCLUSIONS: Working on the WTC debris pile was associated with an elevated risk of post-9/11 sarcoidosis. Occupationally exposed workers may be at increased risk.

BACKGROUND: Few studies have documented the experiences of individuals who participated in the recovery and cleanup efforts at the World Trade Center Recovery Operation at Fresh Kills Landfill, on debris loading piers, and on transport barges after the September 11, 2001 terrorist attack. METHODS: Semi-structured telephone interviews were conducted with a purposive sample of workers and volunteers from the World Trade Center Health Registry. Qualitative methods were used to analyze the narratives. RESULTS: Twenty workers and volunteers were interviewed. They described the transport of debris to the Landfill via barges, the tasks and responsibilities associated with their post-9/11 work at the Landfill, and their reflections on their post-9/11 experiences. Tasks included sorting through debris, recovering human remains, searching for evidence from the terrorist attacks, and providing food and counseling services. Exposures mentioned included dust, fumes, and odors. Eight years after the World Trade Center disaster, workers expressed frustration about poor risk communication during recovery and cleanup work. Though proud of their contributions in the months after 9/11, some participants were concerned about long-term health outcomes. CONCLUSIONS: This qualitative study provided unique insight into the experiences, exposures, and concerns of understudied groups of 9/11 recovery and cleanup workers. The findings are being used to inform the development of subsequent World Trade Center Health Registry exposure and health assessments.