Trends in respiratory diagnoses and symptoms of firefighters exposed to the World Trade Center disaster: 2005-2010.

OBJECTIVES: To compare the prevalence of self-reported respiratory diagnoses in World Trade Center-exposed Fire Department of New York City firefighters to the prevalence in demographically similar National Health Interview Survey participants by year; and, 2) to describe the prevalence of World Trade Center-related symptoms up to 9 years post-9/11. METHODS: We analyzed 45,988 questionnaires completed by 10,999 firefighters from 10/2/2001 to 9/11/2010. For comparison of diagnosis rates, we calculated 95% confidence intervals around yearly firefighter prevalence estimates and generated odds ratios and confidence intervals to compare the odds of diagnoses in firefighters to the National Health Interview Survey prevalence, by smoking status. RESULTS: Overall, World Trade Center-exposed firefighters had higher respiratory diagnosis rates than the National Health Interview Survey; Fire Department of New York City rates also varied less by smoking status. In 2009, bronchitis rates in firefighters aged 45-65 were 13.3 in smokers versus 13.1 in never-smokers while in the National Health Interview Survey, bronchitis rates were doubled for smokers: 4.3 vs. 2.1. In serial cross-sectional analyses, the prevalence of most symptoms stabilized by 2005, at ~10% for cough to ~48% for sinus. CONCLUSIONS: We found generally higher rates of respiratory diagnoses in World Trade Center-exposed firefighters compared to US males, regardless of smoking status. This underscores the impact of World Trade Center exposure and the need for continued monitoring and treatment of this population.

Trends in probable PTSD in firefighters exposed to the World Trade Center disaster, 2001-2010.

OBJECTIVE: We present the longest follow-up, to date, of probable posttraumatic stress disorder (PTSD) after the 2001 terrorist attacks on the World Trade Center (WTC) in New York City firefighters who participated in the rescue/recovery effort. METHODS: We examined data from 11,006 WTC-exposed firefighters who completed 40,672 questionnaires and reported estimates of probable PTSD by year from serial cross-sectional analyses. In longitudinal analyses, we used separate Cox models with data beginning from October 2, 2001, to identify variables associated with recovery from or delayed onset of probable PTSD. RESULTS: The prevalence of probable PTSD was 7.4% by September 11, 2010, and continued to be associated with early arrival at the WTC towers during every year of analysis. An increasing number of aerodigestive symptoms (hazard ratio [HR] 0.89 per symptom, 95% confidence interval [CI] 0.86-.93) and reporting a decrease in exercise, whether the result of health (HR 0.56 vs no change in exercise, 95% CI 0.41-.78) or other reasons (HR 0.76 vs no change in exercise, 95% CI 0.63-.92), were associated with a lower likelihood of recovery from probable PTSD. Arriving early at the WTC (HR 1.38 vs later WTC arrival, 95% CI 1.12-1.70), an increasing number of aerodigestive symptoms (HR 1.45 per symptom, 95% CI 1.40-1.51), and reporting an increase in alcohol intake since September 11, 2001 (HR 3.43 vs no increase in alcohol intake, 95% CI 2.67-4.43) were associated with delayed onset of probable PTSD. CONCLUSIONS: Probable PTSD continues to be associated with early WTC arrival even 9 years after the terrorist attacks. Concurrent conditions and behaviors, such as respiratory symptoms, exercise, and alcohol use also play important roles in contributing to PTSD symptoms.

Predictors of acceptance of H1N1 influenza vaccination by FDNY firefighters and EMS workers.

BACKGROUND: There is a widely recognized need for vaccination of health care workers (HCWs). We undertook this study to assess the 2009-2010 H1N1 vaccination rates in ∼14,000 firefighters and emergency medical service (EMS) workers at the Fire Department of New York (FDNY) and to determine predictors of H1N1 vaccine acceptance. METHODS: After 9/11/01, FDNY developed a bio-preparedness drill where units are dispatched to FDNY-BIOPOD (biologic points of distributions) for rapid distribution of medications/vaccines in the event of a biological disaster. Since 2005, FDNY offers free, voluntary seasonal influenza vaccination during routine medical monitoring/treatment examinations and at FDNY-BIOPOD. In 2009, FDNY-BIOPOD instead offered the H1N1 vaccine. We report on FDNY H1N1 vaccination rates and on predictors of acceptance using bivariate and multivariable techniques. RESULTS: Overall, 10,612 (77%) FDNY workers were offered H1N1 vaccination, of whom 5831 (55%) accepted. Acceptance was 57.2% during FDNY-BIOPOD compared with 34.4% during medical monitoring/treatment exams (p=0.0001). Workers who accepted prior seasonal influenza vaccinations were 4 times more likely to accept H1N1 vaccination (AOR=4.4, CI(95)=4.0-4.8). CONCLUSION: FDNY offered H1N1 vaccination to 77% of its workforce during the 2009-2010 season. Prior seasonal vaccine acceptance and vaccination in a group setting such as FDNY-BIOPOD dramatically increased acceptance of the H1N1 vaccine. However, within a voluntary program, additional strategies are needed to further increase vaccine acceptance in first responders and other HCWs.

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.

Performance characteristics of the PTSD Checklist in retired firefighters exposed to the World Trade Center disaster.

BACKGROUND: Since the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department, City of New York Monitoring Program has provided physical and mental health screening services to rescue/recovery workers. This study evaluated performance of the self-report PTSD Checklist (PCL) as a screening tool for risk of posttraumatic stress disorder (PTSD) in firefighters who worked at Ground Zero, compared with the interviewer-administered Diagnostic Interview Schedule (DIS). METHODS: From December 2005 to July 2007, all retired firefighter enrollees completed the PCL and DIS on the same day. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and Youden index (J) were used to assess properties of the PCL and to identify an optimum cutoff score. RESULTS: Six percent of 1,915 retired male firefighters were diagnosed with PTSD using the DIS to assess DSM-IV criteria. Depending on the PCL cutoff, the prevalence of elevated risk relative to DSM-IV criteria varied from 16% to 22%. Youden index identified an optimal cutoff score of 39, in contrast with the frequently recommended cutoff of 44. At 39, PCL sensitivity was 0.85, specificity was 0.82, and the area under the ROC curve was 0.91 relative to DIS PTSD diagnosis. CONCLUSIONS: This is the first study to validate the PCL in retired firefighters and determine the optimal cutoff score to maximize opportunities for PTSD diagnosis and treatment.

Evaluating risk factors and possible mediation effects in posttraumatic depression and posttraumatic stress disorder comorbidity.

OBJECTIVES: On September 11, 2001 (9/11), attacks on the World Trade Center (WTC) killed 341 Fire Department of the City of New York (FDNY) firefighters and injured hundreds more. Previous WTC-related studies reported high rates of comorbid depression and posttraumatic stress disorder (PTSD), identifying disability retirement, alcohol use, and early arrival at the WTC site as correlates. However, those studies did not evaluate risk factors that could have mediated the observed comorbidity. We identified unique risk factors for each condition in an effort to better understand comorbidity. METHODS: We screened retired WTC-exposed firefighters using self-administered questionnaires including the Center for Epidemiologic Studies Depression Scale, the Post Traumatic Stress Disorder Checklist, and the Alcohol Use Disorders Identification Test. We performed regression analyses to compare independent predictors of elevated depression and PTSD risk, and also tested a mediation hypothesis. RESULTS: From December 2005 to July 2007, 23% and 22% of 1,915 retirees screened positive for elevated depression and PTSD risk, respectively, with comorbidity > 70%. Controlling for comorbidity, we identified unique risk factors for (1) depression: problem alcohol use and (2) PTSD: early arrival at the WTC site. CONCLUSIONS: Our data support the premise that PTSD and depression are different responses to trauma with unique risk factors. The data also suggest a hypothesis that PTSD mediates the relationship between early WTC arrival and depression, while depression mediates the relationship between alcohol use and PTSD, a more complex relationship than shown in previous studies. Clinicians should consider these factors when evaluating patients for depression and PTSD.

Prevalence and incidence of high risk for obstructive sleep apnea in World Trade Center-exposed rescue/recovery workers.

PURPOSE: World Trade Center (WTC)-exposed rescue/recovery workers continue to have high rates of gastroesophageal reflux disease (GERD), chronic rhinosinusitis, and posttraumatic stress disorder (PTSD) symptoms. This study examines the relationship between these WTC-related conditions and being at high risk for obstructive sleep apnea (OSA). MATERIALS AND METHODS: The Fire Department of the City of New York (FDNY) performs periodic health evaluations on FDNY members every 12 to 18 months. Evaluations consist of physician examinations and self-administered health questionnaires, which, since 2005, have incorporated questions about sleep problems that were adapted from the Berlin Questionnaire. The study population consisted of 11,701 male firefighters and emergency medical service personnel. Incidence analyses were limited to a cohort (n = 4,576) who did not meet the criterion for being at high risk for OSA at baseline (between September 12, 2005 and September 8, 2006) and had at least one follow-up assessment, on average, 1.4 (±0.5) years later. RESULTS: The baseline prevalence of high risk for OSA was 36.5%. By follow-up, 16.9% of those not at high risk initially became at high risk for OSA. In multivariable logistic regression models predicting incident high risk for OSA, independent predictors included: earlier time of arrival at the WTC site, GERD, chronic rhinosinusitis, PTSD symptoms, self-assessed fair/poor health, low body mass index (BMI < 18.5 kg/m(2)), and, as expected, BMI > 30 kg/m(2) and weight gain of ≥10 lb (4.5 kg). CONCLUSIONS: We found significant associations between being at high risk for OSA and common WTC-related conditions, although the responsible causative mechanisms remain unknown. Since the etiology of OSA is likely multifactorial, improvement may require successful treatment of both OSA and its comorbid conditions.

Longitudinal study of probable post-traumatic stress disorder in firefighters exposed to the World Trade Center disaster.

BACKGROUND: Symptoms of post-traumatic stress disorder (PTSD) have been reported even years after the terrorist attacks of September 11, 2001 (9/11). METHODS: We used screening tools to assess the prevalence of probable PTSD in 9/11-exposed firefighters at two time points, within 6 months of 9/11 (baseline) and 3-4 years post-disaster (follow-up). RESULTS: Five thousand six hundred fifty-six individuals completed assessments at both times. 15.5% reported probable PTSD post-9/11, 8.6% at baseline and 11.1% at follow-up, on average 2.9 (SD 0.5) years later. Analyses revealed that nearly half of all probable PTSD occurred as delayed onset (absent baseline, present follow-up). Compared with the resilient group (no probable PTSD at either time), probable PTSD at baseline, and delayed onset at follow-up were each associated with concomitant functional impairment (OR 19.5 and 18.9), respectively. CONCLUSION: Similar percentages of firefighters met criteria for baseline and delayed onset probable PTSD at follow-up, years later. Both were associated with substantial functional impairment. Early risk identification could provide opportunities for mental health interventions before symptoms compromise work and social relationships.

Quality of life in relation to upper and lower respiratory conditions among retired 9/11-exposed firefighters with pulmonary disability.

PURPOSE: To examine health-related quality of life (HRQoL) and World Trade Center (WTC) cough syndrome conditions in male firefighters who retired due to a 9/11-related pulmonary disability. METHODS: From 3/1/2008 to 1/31/2009, we contacted 275 disability-retired firefighters and compared their HRQoL and current aerodigestive conditions to those from WTC-exposed non-disabled retired and active firefighters. Relationships between HRQoL and explanatory variable(s) were examined using multivariable linear regression models. RESULTS: Mean physical component summary (PCS) scores were lowest in disabled retirees compared with non-disabled retirees and actives: 36.4 (9.6), 49.4 (8.7), and 53.1 (5.1), respectively (P < 0.0001). Mean mental component summary (MCS) scores were closer: 44.5 (11.9), 48.1 (8.5), and 48.7 (7.4), respectively (P < 0.0001). In multivariable models, after adjustment for many factors, PCS scores were not associated with early WTC arrival, but were inversely associated with disability retirement and all WTC cough syndrome conditions. MCS scores were inversely associated with early WTC arrival and most WTC cough syndrome conditions, but were not associated with disability retirement. CONCLUSION: WTC cough syndrome conditions predict lower HRQoL scores even 8 years after exposure, independent of retirement status. These data suggest that monitoring physical conditions of individuals with occupational exposures might help identify those at risk for impaired HRQoL.

Trends of elevated PTSD risk in firefighters exposed to the World Trade Center disaster: 2001-2005.

OBJECTIVES: We identified trends in the prevalence of elevated posttraumatic stress disorder (PTSD) risk as determined by the Fire Department of the City of New York (FDNY)-modified PTSD Checklist in World Trade Center (WTC)-exposed firefighters. We also examined trends in relation to WTC exposure, social support, change in recreational activities, and functional health. METHODS: We analyzed 16,826 questionnaires from 10,074 firefighters in yearly intervals, from September 12, 2001, to September 11, 2005. RESULTS: The prevalence of elevated PTSD risk increased over time, from 9.8% in year 1 to 10.6% in year 4 (p < 0.0001). Earliest arrival at the WTC site (odds ratio [OR] = 6.0; 95% confidence interval [CI] 4.4, 8.3), prolonged work at the site (OR = 2.0; 95% CI 1.8, 2.3), providing supervision without previous supervisory experience (OR = 4.1; 95% CI 2.8, 6.1), and retirement due to a WTC-related disability (OR=1.3; 95% CI 1.1, 1.5) were associated with ever having elevated PTSD risk. Difficulty functioning at home was strongly associated with elevated PTSD risk (ORs ranged from 17.0 [95% CI 14.5, 20.0] in year 1 to 26.7 [95% CI 20.3, 35.2] in year 3), as was difficulty functioning at work (ORs ranged from 12.1 [95% CI 10.2, 14.2] in year 1 to 23.0 [95% CI 14.6, 36.3] in year 2). CONCLUSIONS: Elevated PTSD risk was associated with exposure to the WTC site as well as functional impairment, and remained largely unabated during the first four years of the study. Screening for elevated PTSD risk may be useful in identifying those who could benefit from interventions during long-term follow-up, as well as in the immediate aftermath of disasters.

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.

Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust.

BACKGROUND: The World Trade Center (WTC) collapse produced a massive exposure to respirable particulates in New York City Fire Department (FDNY) rescue workers. This group had spirometry examinations pre-September 11, 2001, and post-September 11, 2001, demonstrating declines in lung function with parallel declines in FEV(1) and FVC. To date, the underlying pathophysiologic cause for this has been open to question. METHODS: Of 13,234 participants in the FDNY-WTC Monitoring Program, 1,720 (13%) were referred for pulmonary subspecialty evaluation at a single institution. Evaluation included 919 full pulmonary function tests, 1,219 methacholine challenge tests, and 982 high-resolution chest CT scans. RESULTS: At pulmonary evaluation (median 34 months post-September 11, 2001), median values were FEV(1) 93% predicted (interquartile range [IQR], 83%-101%), FVC 98% predicted (IQR, 89%-106%), and FEV(1)/FVC 0.78 (IQR, 0.72-0.82). The residual volume (RV) was 123% predicted (IQR, 106%-147%) with nearly all participants having normal total lung capacity, functional residual capacity, and diffusing capacity of carbon monoxide. Also, 1,051/1,720 (59%) had obstructive airways disease based on at least one of the following: FEV(1)/FVC, bronchodilator responsiveness, hyperreactivity, or elevated RV. After adjusting for age, gender, race, height and weight, and tobacco use, the decline in FEV(1) post-September 11, 2001, was significantly correlated with increased RV percent predicted (P < .0001), increased bronchodilator responsiveness (P < .0001), and increased hyperreactivity (P = .0056). CT scans demonstrated bronchial wall thickening that was significantly associated with the decline in FEV(1) post-September 11, 2001 (P = .024), increases in hyperreactivity (P < .0001), and increases in RV (P < .0001). Few had evidence for interstitial disease. CONCLUSIONS: Airways obstruction was the predominant physiologic finding underlying the reduction in lung function post-September 11, 2001, in FDNY WTC rescue workers presenting for pulmonary evaluation.

Validation of the Center for Epidemiologic Studies Depression Scale in screening for major depressive disorder among retired firefighters exposed to the World Trade Center disaster.

BACKGROUND: We evaluated the performance of a modified Center of Epidemiologic Studies Depression Scale (CES-D-m), which captured symptoms in the past month, in comparison to the Diagnostic Interview Schedule (DIS) in identification of major depressive disorder (MDD) in World Trade Center (WTC)-exposed retired Fire Department, City of New York (FDNY) firefighters. METHODS: From 12/2005 to 7/2007, FDNY enrolled retired firefighters in its Medical Monitoring and Treatment Program. All participants completed the CES-D-m and the DIS on the same day. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and Youden's index were used to assess properties of the CES-D-m. Multivariate logistic regression analyses were also used. RESULTS: 7% of 1915 retired male firefighters were diagnosed with MDD using the DIS. Using the most common CES-D cutoff score of 16, the prevalence of elevated risk was 36%, which declined to 23% using a cutoff score of 22, as determined by Youden's index. At 22, CES-D-m sensitivity was 0.84, specificity was 0.82, and the area under the ROC curve was 0.89 relative to DIS MDD diagnosis. LIMITATIONS: Participants were more likely than non-participants to live in the New York City area. CONCLUSIONS: This is the first study of WTC rescue/recovery workers to assess the performance of a one-month version of the CES-D. The CES-D-m performed well in identifying those at elevated risk. Since diagnostic follow-up is time consuming and costly, it is important to correctly distinguish those at elevated risk using a screening tool that has been validated in the population under study.

Trends in respiratory symptoms of firefighters exposed to the world trade center disaster: 2001-2005.

BACKGROUND: Respiratory symptoms, either newly reported after the World Trade Center (WTC) disaster on 11 September 2001 (9/11) or increased in severity, have been well documented in WTC-exposed workers and New York City residents. However, considerable uncertainty exists over the persistence of symptoms. OBJECTIVES: In this study, our goals were to describe trends in post-9/11 respiratory and gastro-esophageal reflux disease (GERD) symptoms in WTC-exposed firefighters and to examine symptom progression in the cohort that completed both year 1 and year 4 questionnaires. METHODS: We analyzed questionnaire responses from 10,378 firefighters in yearly intervals, from 2 October 2001 to 11 September 2005, defining exposure based on arrival time at the WTC site. For the cohort of 3,722 firefighters who completed the two questionnaires, we also calculated exposure duration summing months of work at the site. RESULTS: In cross-sectional analyses, the prevalence of dyspnea, wheeze, rhinosinusitis, and GERD remained relatively stable, whereas cough and sore throat declined, especially between 1 and 2 years post-9/11. We found a dose-response relationship between arrival time and symptoms in all years (p < 0.01). Logistic models of symptoms at year 4 in the cohort demonstrated independent effects of earlier arrival and longer work duration: each additional month of work increased the odds of symptoms 8-11%. CONCLUSIONS: Protracted work exposures increased the odds of respiratory and GERD symptoms 4 years later. In most large disasters, exposures may be unavoidable during the rescue phase, but our data strongly suggest the need to minimize additional exposures during recovery and cleanup phases.

Trial of prophylactic inhaled steroids to prevent or reduce pulmonary function decline, pulmonary symptoms, and airway hyperreactivity in firefighters at the world trade center site.

BACKGROUND: Inhaled corticosteroids (ICS) are the most effective anti-inflammatory treatment for asthmatics. This trial evaluated the effects of prophylactic ICS in firefighters exposed to the World Trade Center disaster. METHODS: Inhaled budesonide via a dry powder inhaler (Pulmicort Turbuhaler, AstraZeneca, Wilmington, DE) was offered on-site to New York City firefighters between September 18 and 25, 2001. One to 2 years later, firefighters (n = 64) who completed 4 weeks of daily ICS treatment were evaluated and compared with an age- and exposure-matched comparison group (n = 72) who did not use ICS. RESULTS: When spirometry results at the final visit were compared with those from the weeks following the 9/11 disaster, the treatment group had a greater increase in forced vital capacity (P = .009) and possibly a slower decline in forced expiratory volume at 1 second (P = .11), as well as a greater improvement in perceived well-being as assessed by the St George's Respiratory Questionnaire (P < .01). There was no difference in airway hyperreactivity and no evidence of adverse effects from ICS. CONCLUSIONS: Because the potential for hazardous exposures is great at many disasters, disease prevention programs based on environmental controls and respiratory protection are warranted immediately. Our results suggest that, pending further study with a larger sample, prophylactic ICS should be considered, along with respiratory protection, to minimize possible lung insult.