September 11: Health Effects in the Aftermath of the World Trade
Center Attack (08-SEP-04, GAO-04-1068T).
When the World Trade Center (WTC) buildings collapsed on
September 11, 2001, nearly 3,000 people died and an estimated
250,000 to 400,000 people who were visiting, living, working, and
attending school nearby, or responding to the attack, were
exposed to a mixture of dust, debris, smoke, and various
chemicals. In the months to follow, thousands of people who
returned to the area to live and work, as well as responders who
were involved in the search for remains and site cleanup, were
also exposed. In addition, people in New York City and across the
country were exposed to the emotional trauma of a terrorist
attack on American soil. Concerns have been raised about the
short- and long-term physical and mental health effects of the
attack. Various government agencies and private organizations
established efforts to monitor and understand these health
effects. GAO was asked to describe the health effects that have
been observed in the aftermath of the WTC attack and the efforts
that are in place to monitor and understand those health effects.
GAO searched bibliographic databases such as Medline to determine
the pertinent scientific literature, reviewed that literature,
and interviewed and reviewed documents from government officials,
health professionals, and officials of labor groups.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-04-1068T
ACCNO: A12271
TITLE: September 11: Health Effects in the Aftermath of the
World Trade Center Attack
DATE: 09/08/2004
SUBJECT: Air pollution
Health hazards
Respiratory diseases
Environmental monitoring
Terrorism
Mental illnesses
Health surveys
Public health
World Trade Center (NY)
******************************************************************
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GAO-04-1068T
United States Government Accountability Office
GAO Testimony
Before the Subcommittee on National Security, Emerging Threats, and
International Relations, Committee on Government Reform, House of
Representatives
For Release on Delivery Expected at 10:00 a.m. EDT
Wednesday, September 8, 2004 SEPTEMBER 11
Health Effects in the Aftermath of the World Trade Center Attack
Statement of Janet Heinrich
Director, Health Care-Public Health Issues
GAO-04-1068T
September 8, 2004
SEPTEMBER 11
Health Effects in the Aftermath of the World Trade Center Attack
[IMG]
What GAO Found
In the aftermath of the September 11 attack on the World Trade Center, a
wide variety of physical and mental health effects have been reported in
the scientific literature. The primary health effects include various
injuries, respiratory conditions, and mental health effects. In the
immediate aftermath of the attack, the primary injuries were inhalation
and musculoskeletal injuries. During the 10-month cleanup period, despite
the dangerous work site, responders reported few injuries that resulted in
lost workdays. A range of respiratory conditions have also been reported,
including wheezing, shortness of breath, sinusitis, asthma, and a new
syndrome called WTC cough, which consists of persistent cough accompanied
by severe respiratory symptoms. Almost all the firefighters who responded
to the attack experienced respiratory effects, and hundreds had to end
their firefighting careers due to WTC-related respiratory illness. Unlike
the physical health effects, the mental health effects were not limited to
people in the WTC area but were also experienced nationwide. Because most
of the information about mental health effects comes from questionnaire or
survey data, what is reported in most cases are symptoms associated with a
psychiatric disorder, rather than a clinical diagnosis of disorder. The
most commonly reported mental health effects include symptoms associated
with depression, stress, anxiety, and posttraumatic stress disorder
(PTSD)-a disorder that can develop after experiencing or witnessing a
traumatic event and includes such symptoms as intrusive memories and
distressing dreams-as well as behavioral effects such as increased use of
alcohol and tobacco and difficulty coping with daily responsibilities.
Six programs were established to monitor and understand the health effects
of the attack, and these programs vary in terms of which people are
eligible to participate, methods for collecting information about the
health effects, options for treatment referral, and number of years people
will be monitored. Although five of the programs focus on various
responder populations, the largest program-the WTC Health Registry-is open
not only to responders but also to people living or attending school in
the vicinity of the WTC site, or working or present in the vicinity on
September
11. The monitoring programs vary in their methods for identifying those
who may require treatment, and although none of these programs are funded
to provide treatment, they provide varying options for treatment referral.
Under current plans, HHS funding for the programs will not extend beyond
2009. Some long-term health effects, such as lung cancer, may not appear
until several decades after a person has been exposed to a harmful agent.
GAO provided a draft of this testimony to DHS, EPA, HHS, and the
Department of Labor. In its written comments, HHS noted that the testimony
does not include significant discussion of ways in which mental health
symptoms have changed over time. The evidence GAO examined did not support
a full discussion of changes in mental or physical health effects over
time.
United States Government Accountability Office
Mr. Chairman and Members of the Subcommittee:
I appreciate the opportunity to be here today as you discuss the health
effects of the September 11, 2001, terrorist attack on the World Trade
Center (WTC).1 When the WTC buildings collapsed on that day, nearly 3,000
people died and an estimated 250,000 to 400,000 people were immediately
exposed to a mixture of dust, debris, smoke, and various chemicals.2 These
people included those living, working, and attending school in the
vicinity as well as the thousands of emergency response workers who rushed
to the scene. Also exposed to these substances were the thousands of
responders3 who were involved in some capacity in the rescue operations,
search for remains, and site cleanup in the days, weeks, and months to
follow and the thousands of residents, commuters, and students who
returned to the area to live and work while the cleanup continued.4 In
addition, people in New York City (NYC) and across the country were
exposed to the emotional trauma of a terrorist attack intended to instill
fear and anxiety in the American population.
Concerns have been raised about the short- and long-term physical and
mental health effects of the attack. Experts have stressed the importance
of understanding the health effects related to the attacks and ensuring
that these effects are investigated and that people needing treatment are
identified. Under challenging circumstances due to the unprecedented
nature of the events and the need for rapid response, various government
1A list of abbreviations used in this testimony is given in Appendix I.
2New York City Department of Health and Mental Hygiene and U.S. Department
of Health and Human Services, Agency for Toxic Substances and Disease
Registry, Protocol for the World Trade Center Health Registry (New York,
2003).
3For purposes of this testimony, the term responders refers to anyone
involved in rescue, recovery, and cleanup efforts at or in the vicinity of
the WTC site and Staten Island Fresh Kills landfill (the off-site location
of the WTC recovery operation), including firefighters, law enforcement
officers, emergency medical technicians and paramedics, morticians, health
care professionals, construction workers, ironworkers, carpenters, heavy
equipment operators, mechanics, truck drivers, engineers, laborers,
telecommunications workers, and various federal, state, and local agency
employees who assisted with rescue, recovery, and cleanup activities.
4For more information on exposures to these substances, see, for example,
U.S. Environmental Protection Agency, Exposure and Human Health Evaluation
of Airborne Pollution from the World Trade Center Disaster (External
Review Draft) (Washington, D.C., 2002), and J.D. Pleil et al., "Air Levels
of Carcinogenic Polycyclic Aromatic Hydrocarbons after the World Trade
Center Disaster," Proceedings of the National Academy of Sciences of the
United States of America, vol. 101, no. 32 (2004).
agencies and private-sector organizations established several efforts to
monitor and understand the health effects resulting from the attack. You
asked us to examine these efforts.
In this testimony, we describe (1) health effects that have been observed
in the aftermath of the WTC attack and (2) efforts that are in place to
monitor and understand those health effects. My colleague's testimony
addresses workers' compensation for people who were injured while working
during the attack or its aftermath.5
To describe the health effects of the WTC attack and the efforts to
monitor and understand them, we reviewed the scientific literature related
to efforts to identify, track, or treat the physical and mental health
effects of the September 11 attack6 and interviewed and reviewed documents
from federal, state, and local agency officials, as well as medical and
public health professionals and officials of labor groups. We searched 19
bibliographic databases such as Medline to determine the pertinent
literature. The studies of health effects vary in study design, measures
used, survey instruments, time periods, and populations studied, and thus
in many cases the reported results cannot be directly compared. The
federal, state, and local officials we interviewed were from the U.S.
Departments of Defense (DOD), Education, Health and Human Services (HHS),
Homeland Security (DHS), Justice (DOJ), Labor (DOL), and Veterans Affairs
(VA); the Environmental Protection Agency (EPA); the New York State
Department of Health; the New York State Office of Mental Health; and the
New York City Department of Health and Mental Hygiene. The medical and
public health professionals we interviewed were affiliated with the
Association of Occupational and Environmental Clinics, the City University
of New York's Queens College, the New York City Fire Department's (FDNY)
Bureau of Health Services, the Greater New York Hospital Association, the
Johns Hopkins Bloomberg School of Public Health, the Mailman School of
Public Health at Columbia University, the Mount Sinai-Irving J. Selikoff
Clinical Center for Occupational and Environmental Medicine, the New York
Academy of Medicine, the New York University School of Medicine's Child
Study Center, and the National Child Traumatic Stress Network. We also
interviewed representatives of
5GAO, September 11: Federal Assistance for New York Workers' Compensation
Costs, GAO-04-1013T (Washington, D.C.: Sept. 8, 2004).
6See the bibliography for a list of the scientific literature that we
relied on in producing this testimony.
labor groups, including the American Federation of State, County and
Municipal Employees District Council 37; the Communications Workers of
America; the New York State American Federation of Labor-Congress of
Industrial Organizations; and the Uniformed Firefighters Association.
We relied primarily on data from published, peer-reviewed articles and
government reports and did not independently verify the data contained in
the scientific literature or documents obtained from agency officials and
medical professionals. However, we did review the methods used in the
studies and discussed any questions we had about the studies with their
authors. We determined that the data reported from these studies were
sufficiently reliable for our objectives. We conducted our work from March
2004 through September 2004 in accordance with generally accepted
government auditing standards.
In summary, in the aftermath of the September 11 attack on the World Trade
Center, a wide variety of physical and mental health effects have been
reported in the scientific literature. The primary health effects include
various injuries, respiratory conditions, and mental health effects. In
the immediate aftermath of the attack, the primary injuries were
inhalation and musculoskeletal injuries. During the 10-month cleanup
period, despite the dangerous nature of the work site, responders reported
few injuries that resulted in lost workdays. A range of respiratory
conditions have also been reported, including wheezing, shortness of
breath, sinusitis, asthma, and a new syndrome called WTC cough, which
consists of persistent cough accompanied by severe respiratory symptoms.
Almost all the firefighters who responded to the attack experienced
respiratory effects, and hundreds had to end their firefighting careers
due to WTC-related respiratory illness. Whereas the physical health
effects were limited to people in the WTC area, the mental health effects,
although more pronounced in the NYC area, were experienced nationwide.
Because most of the information about mental health effects comes from
questionnaire or survey data, what is reported in most cases are symptoms
associated with a psychiatric disorder, rather than a clinical diagnosis
of the disorder itself. The most commonly reported mental health effects
include symptoms associated with depression, stress, anxiety, and
posttraumatic stress disorder (PTSD)-an often debilitating and potentially
chronic disorder that can develop after experiencing or witnessing a
traumatic event and includes such symptoms as intrusive memories and
distressing dreams-as well as behavioral effects such as increased use of
alcohol and tobacco and difficulty coping with daily responsibilities.
Six programs have been established by federal, state, and local government
agencies and private organizations to monitor and understand the health
effects of the attack. These programs vary in terms of which people are
eligible to participate, methods for collecting information about the
health effects, options for treatment referral, and number of years people
will be monitored. Although five of the monitoring programs focus on
various responder populations, the largest program-the WTC Health
Registry-is open not only to responders-that is, those involved in the
rescue, recovery, and cleanup efforts-but also to people living or
attending school in the vicinity of the WTC site, or working or present in
the vicinity on September 11. The monitoring programs vary in their
methods for identifying those who may require treatment, and although none
of these programs are funded to provide treatment, they provide varying
options for treatment referral. Under current plans, HHS funding for the
programs will not extend beyond 2009. Some long-term health effects, such
as lung cancer, may not appear until several decades after a person has
been exposed to a harmful agent.
We provided a draft of this testimony to DHS, DOL, EPA, and HHS. In its
written comments, HHS noted that the testimony does not include
significant discussion of ways in which mental health symptoms have
changed over time. The evidence we examined did not support a full
discussion of changes in mental or physical health effects over time. HHS
and the other agencies also provided technical comments, which we
incorporated as appropriate.
Although people across the country were exposed through the media to the
emotional trauma of the WTC attack, the residents, office workers, and
others living, working, or attending school in the WTC area and the WTC
responders not only experienced the traumatic event in person but also
were exposed to a complex mixture of potentially toxic contaminants in the
air and on the ground, such as pulverized concrete, fibrous glass,
particulate matter, and asbestos. Almost 3,000 people, including some who
were trapped above the impact zone and others who entered the buildings to
assist in the evacuation, were killed in the attack.7 The majority of the
estimated 16,400 to 18,800 people who were in the WTC complex that
7National Commission on Terrorist Attacks upon the United States, The 9/11
Commission Report (Washington, D.C., 2004).
Background
morning were able to evacuate, however, with minor or no injuries.8 An
estimated 40,000 responders were at or in the vicinity of the WTC site or
the Staten Island Fresh Kills landfill, participating in rescue, recovery,
and cleanup efforts9; conducting environmental and occupational health
assessments; providing crisis counseling and other treatment; providing
security; and assisting with the criminal investigation.
The responders included personnel from many agencies at the federal,
state, and local levels, as well as from organizations in the private
sector, and various other workers and volunteers. The agencies and
organizations include HHS's Agency for Toxic Substances and Disease
Registry (ATSDR), HHS's Centers for Disease Control and Prevention (CDC),
the Department of Energy, EPA, DOJ's Federal Bureau of Investigation
(FBI), DHS's Federal Emergency Management Agency (FEMA), HHS's National
Institute for Occupational Safety and Health (NIOSH), HHS's National
Institute of Environmental Health Sciences (NIEHS), the Department of the
Interior's National Park Service, DOL's Occupational Safety and Health
Administration (OSHA), HHS's Public Health Service Commissioned Corps,
HHS's Substance Abuse and Mental Health Services Administration (SAMHSA),
DOD's U.S. Coast Guard, DOJ's U.S. Marshals Service, the New York State
Department of Environmental Conservation, the New York State Emergency
Management Office, the New York State National Guard, the New York State
Office of Mental Health, the New York State Department of Health, the
Metropolitan Transportation Authority's New York City Transit, FDNY and
emergency medical services (EMS), the New York City Department of Health
and Mental Hygiene, the New York City Police Department (NYPD), the New
York City Department of Design and Construction, the New York City
Department of Environmental Protection, the New York City Department of
Sanitation, the New York City Office of Emergency Management, the American
Red Cross, and the Salvation Army.
Recognizing a need to monitor and understand the full health effects of
the WTC collapse, officials from various organizations secured federal
funding
8National Commission on Terrorist Attacks upon the United States, 2004.
9Department of Health and Human Services, "HHS Awards $81 Million for
Five-Year Health Screening of World Trade Center Rescue, Recovery
Workers," Department of Health and Human Services,
http://www.hhs.gov/news/press/2004pres/20040318.html (accessed Aug. 9,
2004).
to establish programs to monitor the health of affected people.10 FDNY
sought federal support in order to provide comprehensive medical
evaluations to its firefighters, and established its WTC Medical
Monitoring Program (referred to here as the FDNY program). The Mount Sinai
Clinical Center for Occupational and Environmental Medicine also sought
federal support in the weeks following the attack to develop its WTC
Worker and Volunteer Medical Monitoring Program (referred to here as the
Mount Sinai program).11 Through its Federal Occupational Health (FOH)
services, HHS initiated a WTC responder screening program for federal
workers (referred to here as the FOH program) involved in WTC rescue,
recovery, and cleanup activities. Similarly, the New York State Department
of Health established the medical monitoring program for New York State
responders (referred to here as the NYS program) engaged in emergency
activities related to the September 11 attack. In addition, two registries
were established to compile lists of exposed persons and collect
information through interviews and surveys in order to provide a basis for
understanding the health effects of the attack. The New York City
Department of Health and Mental Hygiene contacted ATSDR in February 2002
to develop the WTC Health Registry. ATSDR provided technical assistance to
the New York City Department of Health and Mental Hygiene and worked with
FEMA to obtain funds for the WTC Health Registry for responders and people
living or attending school in the vicinity of the WTC site, or working or
present in the vicinity on September 11. Separately, Johns Hopkins
received a grant from NIEHS to create another registry
10FEMA provided funds appropriated for disaster relief and emergency
response to the September 11, 2001, terrorist attacks to HHS through
interagency agreements to support monitoring efforts. See Consolidated
Appropriations Resolution, 2003, Pub. L. No. 108-7, 117 Stat. 11, 517; see
also 2002 Supplemental Appropriations Act for Further Recovery from and
Response to Terrorist Attacks on the United States, Pub. L. No. 107-206,
116 Stat. 820, 894; Department of Defense and Emergency Supplemental
Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, 2002, Pub. L. No. 107-117, 115 Stat. 2230, 2338; and
2001 Emergency Supplemental Appropriations Act for Recovery from and
Response to Terrorist Attacks on the United States, Pub. L. No. 107-38,
115 Stat. 220-1.
11Initial medical screenings of responders conducted by this program were
supported by funds appropriated to CDC for disease control, research, and
training. See Department of Defense and Emergency Supplemental
Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, 2002, 115 Stat. at 2313.
Varied Physical and Mental Health Effects Have Been Observed and Reported
across a Wide Range of People
(referred to here as the Johns Hopkins registry) of WTC site workers who
were involved in cleanup efforts.12
A wide variety of physical and mental health effects have been observed
and reported across a wide range of people in the aftermath of the
September 11 attacks. The health effects include various injuries,
respiratory conditions, reproductive health effects, and mental health
effects. Unlike the physical health effects, the mental health effects of
the September 11 attacks were not limited to responders and people who
were in the WTC area but were also experienced by people across the
nation. Because most of the information about mental health effects comes
from questionnaire or survey data, what is reported in most cases are
symptoms associated or consistent with a disorder, such as PTSD, rather
than a clinical diagnosis of a disorder. The most commonly reported mental
health effects were symptoms associated with PTSD, depression, stress, and
anxiety, as well as behavioral effects such as increases in substance use
and difficulties coping with daily responsibilities.
Injuries
Although the total number of people injured during the WTC attack is
unknown, data on hospital visits show that thousands of people were
treated in its immediate aftermath for injuries, including inhalation
injuries, musculoskeletal injuries, burns, and eye injuries. Unpublished
data collected by the Greater New York Hospital Association from September
11 through September 28, 2001, showed 6,232 emergency room visits and 477
hospitalizations related to the attack in 103 hospitals in New York State
and 1,018 emergency room visits and 84 hospitalizations related to the
attack in nearby New Jersey hospitals. These numbers do not include
injured people who may have been treated in more distant New York State,
New Jersey, and Connecticut hospitals, in triage stations,13 or by private
physicians, and those who did not seek professional treatment. More
detailed information on injuries is available from the four hospitals
closest to the WTC and a fifth hospital that served as a burn referral
12The grant was funded by an appropriation to NIEHS to support research,
worker training, and education activities. See Department of Defense and
Emergency Supplemental Appropriations for Recovery from and Response to
Terrorist Attacks on the United States Act, 2002, 115 Stat. at 2337.
13Triage stations are temporary facilities set up in the aftermath of a
disaster where medical assessments of patients are performed to determine
their relative priority for treatment, based on the severity of illness or
injury.
center. According to the New York City Department of Health and Mental
Hygiene, between September 11 and September 13, 2001, these hospitals
treated 790 people, 2 of whom later died, for injuries related to the
attack (CDC, 2002c). The most common of these injuries were
musculoskeletal injuries-such as fractures, sprains, and crush
injuries-and inhalation injuries. The majority of people with injuries
were treated and released, although about 18 percent required
hospitalization.14
In addition, thousands of responders were treated for injuries, a small
proportion of which were classified as serious, during the 10-month
cleanup period. The disaster site was considered to be extremely
dangerous, yet no additional life was lost after September 11. Using data
from five Disaster Medical Assistance Teams (DMAT) temporary medical
facilities15 and the four hospitals closest to the WTC site, researchers
documented 5,222 visits by rescue workers to DMAT facilities and emergency
rooms in the first month of the cleanup period (Berrios-Torres et al.,
2003). During this month, musculoskeletal injuries were the leading cause
of rescue worker visits and hospitalizations. Other injuries included
burns and eye injuries. According to OSHA, despite logging more than 3.7
million work hours over the 10-month cleanup period, WTC site workers
reported only 57 injuries that OSHA classified as serious because they
resulted in lost workdays, yielding a lost workday injury rate of 3.1
injuries per 100 workers per year. This rate is lower than that seen in
the type of construction deemed by OSHA to be the most similar to the WTC
cleanup, specialty construction, which has a lost workday injury rate of
4.3.
Respiratory Health Effects A range of respiratory health effects,
including a new syndrome called WTC cough and chronic diseases such as
asthma, were observed among people exposed to the WTC collapse and its
aftermath. Many of the programs examining respiratory health effects are
ongoing and have published only preliminary results. Nevertheless, the
studies present a
14In an assessment of the cardiovascular effects of the WTC attack in
eight hospitals in NYC, no significant increases in hospitalization for
cardiac events immediately following the attack were found (Chi et al.,
2003).
15The DMAT facilities were set up around the disaster site by FEMA's
National Disaster Medical System, which was activated on September 11. The
DMATs maintained a 24-hour presence at the WTC site for 2 months after the
disaster. In addition to the DMATs, the National Disaster Medical System
also includes teams of morticians, veterinarians, nurses, pharmacists, and
management personnel.
FDNY Firefighters
consistent collection of conditions among those people who were involved
in rescue, recovery, and cleanup as well as those who lived and worked in
the WTC vicinity. The most commonly reported conditions include cough,
wheezing, shortness of breath, sinusitis, and asthma. Many of the findings
on respiratory effects published to date have focused on firefighters, and
FDNY medical staff first described WTC cough, which consists of persistent
cough accompanied by severe respiratory symptoms,16 often in conjunction
with sinusitis, asthma, and gastroesophageal reflux disease (GERD).17
Several studies report on other WTC responders, such as the police,
ironworkers, and cleanup workers, and a few studies report on the
respiratory effects among people living and working in lower Manhattan.
Almost all of the FDNY firefighters who had responded to the attack
experienced respiratory effects, and hundreds had to end their
firefighting careers due to WTC-related respiratory illness. Within 48
hours of the attack, FDNY found that about 90 percent of its 10,116
firefighters and EMS workers who were evaluated at the WTC site reported
an acute cough. The FDNY Bureau of Health Services also noted wheezing,
sinusitis, sore throats, asthma, and GERD among firefighters who had been
on the scene. During the first 6 months after the attack, FDNY observed
that of the 9,914 firefighters who were present at the WTC site within 7
days of the collapse, 332 firefighters had WTC cough (Prezant et al.,
2002). Eighty-seven percent of the firefighters with WTC cough reported
symptoms of GERD. According to the FDNY Bureau of Health Services,
symptoms of GERD are typically reported by less than 25 percent of
patients with chronic cough. Some FDNY firefighters exhibited WTC cough
that was severe enough for them to require at least 4 weeks of medical
leave. Despite treatment of all symptoms, 173 of the 332 firefighters and
one EMS technician with WTC cough showed only partial improvement. FDNY
also found that the risk of reactive airway dysfunction syndrome, or
irritant-induced asthma, and WTC cough was associated with intensity of
the exposure, defined as the time of arrival at the site (Banauch et al.,
2003). In addition, FDNY reports that one firefighter who worked 16-hour
days for 13 days and did not use
16Severe respiratory symptoms are defined by the FDNY Bureau of Health
Services as symptoms that are severe enough to require at least 4
consecutive weeks of medical leave.
17GERD occurs when the lower esophageal sphincter does not close properly
and stomach contents leak back, or reflux, into the esophagus. When
refluxed stomach acid touches the lining of the esophagus, it causes a
burning sensation in the chest or throat called heartburn.
Other WTC Responders
People Living or Working in Lower Manhattan
respiratory protection during the first 7 to 10 days was diagnosed with a
rare form of pneumonia that results from acute high dust exposure (Rom et
al., 2002). According to an official from the FDNY Bureau of Health
Services, because one of the criteria for being a firefighter is having no
respiratory illness, about 380 firefighters were no longer able to serve
as firefighters as of March 2004 as a consequence of respiratory illnesses
they developed after WTC exposure.
Studies and screenings conducted among other responders-carpenters,
cleanup workers, federal civilian employees, heavy equipment operators,
ironworkers, mechanics, National Guard members, police officers,
telecommunications technicians, truck drivers, and U.S. Army military
personnel-have found respiratory health effects similar to those seen in
FDNY firefighters. Some of the responders with existing respiratory
conditions reported that symptoms worsened, and others reported that they
developed new respiratory symptoms on or after September 11. The most
commonly reported symptom was cough. For example, about 63 percent of
officers from NYPD's Emergency Services Unit who were evaluated about 1 to
4 months after September 11 reported having a cough (Salzman et al.,
2004). Other symptoms observed among responders included chest tightness,
nasal congestion, shortness of breath, sore throat, and wheezing.
Unpublished results from respiratory health assessments of WTC site
workers-including truck drivers, heavy equipment operators, mechanics,
laborers, and carpenters-conducted by Johns Hopkins in December 2001 show
that among those who reported no previous history of lower respiratory
symptoms, 34 percent reported developing a cough and 19 percent reported
wheezing. While some responders reported that symptoms improved or
resolved a few months after the attack, others reported that they
continued to experience symptoms. For example, initial results from
screenings of 250 participants in Mount Sinai's monitoring program show
that 46 percent of these responders were still experiencing at least one
pulmonary symptom and 52 percent were still experiencing an ear, nose, or
throat symptom 9 months after the attack (Herbert and Levin, 2003).
Surveys conducted among people living or working in lower Manhattan show
that these people experienced respiratory health effects similar to those
experienced by responders, such as nose or throat irritation and cough.
For example, a door-to-door survey conducted by the New York City
Department of Health and Mental Hygiene in three residential areas in
lower Manhattan between October 25 and November 2, 2001, showed that the
most frequently reported symptoms were nose or throat irritation (about 66
percent) and cough (about 47 percent) (CDC, 2002a). A NIOSH
survey of federal employees working near the WTC site found that 56
percent of respondents reported having a cough (Trout et al., 2002). Other
symptoms observed among those living or working in lower Manhattan include
chest tightness, head or sinus congestion, shortness of breath, and
wheezing. Some people reported that the WTC collapse and its aftermath
exacerbated existing respiratory conditions, such as asthma, and others
reported symptoms that developed after September 11, 2001. For example, a
review of medical charts of children with existing asthma from a lower
Manhattan clinic found that after September 11 there was a significant
increase in asthma-related clinic visits among children who lived within 5
miles of the WTC site (Szema et al., 2004). Unpublished preliminary
findings from a New York State Department of Health survey of NYC
residents found that almost three-fourths of respondents living near the
WTC site experienced new upper respiratory symptoms after September 11.
Reproductive Health Effects
For all measures of reproductive health studied except birth weight for
gestational age,18 no differences were found between infants born to women
who were in or near the WTC on September 11 and infants of those who were
not. The Mount Sinai School of Medicine conducted a study of the 187
pregnant women19 who were either in or near the WTC on September 11. This
study found no significant differences in average gestational duration at
birth or average birth weight between infants of the women who were in or
near the WTC on September 11 during their pregnancy and infants of the
2,367 women in the study's comparison group, who were not (Berkowitz et
al., 2003). Additionally, no significant differences in frequency of
preterm births (less than 37 weeks of gestation) or in incidence of low
birth weight (less than 2,500 grams) were observed. Nor was an association
observed between symptoms of posttraumatic stress in the mother and
frequency of preterm birth, low birth weight, or
small-for-gestational-age20 infants. However, 8.2 percent of
18Gestation is the period between conception and birth of a baby, and
gestational age is duration of gestation.
19Of the 187 women, 3 miscarried and 2 were unavailable for follow-up,
leaving 182 women with live births. The last delivery occurred in June
2002.
20The term "small for gestational age" (SGA) means a fetus or infant is
smaller in size than is expected for the baby's sex, genetic heritage, and
duration of gestation. Birth weight below the population tenth percentile,
taking into account gestational age, is the most widely used definition of
SGA.
infants born to women who were in or near the WTC on September 11 were
born with a birth weight below the tenth percentile for gestational age,
compared to 3.8 percent of infants born to women in the study's control
group. This difference was still statistically significant after variables
such as maternal age, race/ethnicity, sex of the infant, and maternal
smoking history were taken into account.21 Because
small-forgestational-age infants are at risk for developmental problems,
the Mount Sinai program includes a follow-up study in which researchers
plan to obtain physical measurements of growth and perform assessments of
early cognitive development.
Symptoms Associated with PTSD
In the weeks and months after the WTC attack, people living, working, or
attending school in NYC and responders involved in the rescue, recovery,
and cleanup reported symptoms associated with PTSD, as did people across
the nation. PTSD is an often debilitating and potentially chronic disorder
that can develop after experiencing or witnessing a traumatic event. It
includes such symptoms as difficulty sleeping, irritability or anger,
detachment or estrangement, poor concentration, distressing dreams,
intrusive memories and images, and avoidance of reminders of the trauma.
People living or working near the WTC site reported a higher rate of
symptoms associated with PTSD than did those living or working farther
from the site. For example, researchers found that about 7.5 percent of
Manhattan residents reported symptoms consistent with PTSD 5 to 8 weeks
after the attack, with 20 percent of those living in close proximity to
the WTC reporting symptoms (Galea et al., 2002a). Similarly, NIOSH surveys
found that reports of symptoms consistent with PTSD were significantly
higher among school staff in the WTC vicinity than among school staff
working at least 6 miles from the WTC site (CDC, 2002a).
21Additionally, an unpublished study conducted by the Mailman School of
Public Health at Columbia University found no differences in birth weight,
length, head circumference, or Apgar scores (the Apgar is a test performed
at 1 and 5 minutes after birth to determine the physical condition of the
newborn). However, in this study, the gestational duration observed among
pregnant women who lived or worked near the WTC during the 2 weeks after
September 11 was shorter than that of those who did not (274.3 versus
275.9 days). Though this difference was statistically significant, its
clinical significance is unclear. Researchers planned to assess cognitive
and motor functions of the infants at a 1-year follow-up visit.
Some groups of people, such as children and responders, were found to have
experienced traumatic reactions to the attack. For example, a citywide
survey of a representative sample of NYC fourth to twelfth graders 6
months after the attack found that over 10 percent reported having
symptoms consistent with PTSD. The researchers who conducted this survey
noted that these symptoms were five times more prevalent than
pre-September 11 rates reported for other communities (Hoven et al.,
2002). Responders, many of whom lost colleagues, were also affected.
Initial findings from the Mount Sinai program show that about 22 percent
of a sample of 250 WTC responders reported symptoms consistent with PTSD
(Herbert and Levin, 2003).
People across the nation also reported symptoms associated with PTSD. A
nationwide survey comparing reactions in NYC to those across the country
using a nationally representative sample of U.S. adults found that the
prevalence of symptoms associated with PTSD 1 to 2 months after the attack
was significantly higher in the NYC metropolitan area (11.2 percent) than
in other major metropolitan areas (3.6 percent) and the rest of the
country (4 percent) (Schlenger et al., 2002). Another nationally
representative sample in a nationwide survey of U.S. adults shows that 17
percent of the U.S. population outside of NYC reported symptoms associated
with PTSD 2 months after the attack (Silver et al., 2002). Although no
baseline data are available on the prevalence of symptoms related to PTSD,
typically about 3.6 percent of U.S. adults have a psychiatric diagnosis of
PTSD during the course of a year.22
Symptoms Associated with Depression, Stress, and Anxiety
People living, working, and attending school in NYC and WTC responders, as
well as people across the nation, reported symptoms associated with
depression, stress, and anxiety. For example, in NYC, researchers found
that about 9.7 percent of Manhattan residents surveyed 5 to 8 weeks after
the attack reported symptoms consistent with depression (Galea et al.,
2002a). Nine hospitals in NYC reported that from September 11 to September
24, 2001, the predominant symptoms related to the WTC attack were those
associated with anxiety, stress, and depression (Greater New York Hospital
Association, 2001). Data from these hospitals show that anxiety declined
over the month following the attack but increased again
22Department of Veterans Affairs, "What Is Posttraumatic Stress Disorder?
A National Center for PTSD Fact Sheet,"
www.ncptsd.org/facts/general/fs_what_is_ptsd.html, updated May 14, 2003
(accessed Aug. 16, 2004).
around the time that the first case of anthrax in NYC was announced in
mid-October 2001. A NIOSH survey of people working in schools near the WTC
site also reported symptoms of depression (CDC, 2002a). Among the
responders, initial screenings from the Mount Sinai program show that
nearly 37 percent of 250 program participants reported symptoms associated
with anxiety, insomnia, and depression (Herbert and Levin, 2003). In
addition, a nationwide survey conducted 3 to 5 days after the attack in a
nationally representative sample of U.S. adults found that 44 percent of
those surveyed reported one or more substantial symptoms of stress,
including having difficulty concentrating, feeling irritable, feeling
upset when something reminds the person of the attack, having disturbing
thoughts or dreams, and having trouble sleeping (Schuster et al., 2001).
Behavioral Effects
The behavioral effects in the aftermath of the WTC attack included
increased use of substances such as alcohol, tobacco, and marijuana.
Increased use of alcohol and tobacco was identified through surveys of the
general population conducted by the states of Connecticut, New Jersey, and
New York in the 3 months following the attack (CDC, 2002b). In Manhattan,
researchers found that almost 29 percent of people who responded to a
survey administered 5 to 8 weeks after September 11 reported increased use
of cigarettes, alcohol, or marijuana after the attack (Vlahov et al.,
2002). According to these researchers, this increase in substance use was
still evident 6 months after September 11 (Vlahov et al., 2004a,b).
The behavioral effects also included difficulty coping with daily
responsibilities. Some NYC children and adolescents, family members, and
other adults, including members of the response community, are still
having difficulty coping 3 years after September 11. For example, an
ongoing SAMHSA-supported youth mental health program in NYC is treating
220 children and adolescents who are having problems coping, such as
having difficulties functioning in school. In addition, researchers
affiliated with the New York University School of Medicine's Child Study
Center's bereavement program for families of uniformed personnel killed in
responding to the WTC attacks noted that the psychological and emotional
reactions of children and adolescents directly affected by the attacks
have diminished somewhat over time but that some children continue to be
affected by the emotional state and coping difficulties of their parents.
Of particular concern to these researchers are the widowed mothers, who
are experiencing sustained distress at twice the level typically found in
the general population and are having difficulty coping with their daily
responsibilities, such as single parenthood, almost 3 years
Programs Established to Monitor and Understand Health Effects Vary in
Eligibility Requirements, Methods, Treatment Referrals, and Duration
later. Some responders, such as members of FDNY, also report having
difficulty coping in the aftermath of September 11.
The programs established to monitor and understand the health effects of
the attack vary in terms of which people are eligible to participate,
methods for collecting information about the health effects, options for
treatment referral, and number of years people will be monitored. (See
table 1.) FEMA provided funding for most of these programs through
interagency agreements with HHS. These programs are not centrally
coordinated, but some of them are collaborating with each other.
Table 1: Programs to Monitor Health Effects in the Aftermath of the World
Trade Center (WTC) Attack
Eligible Monitoring Treatment Intended Duration and Administrator
Populations Participation Methods Referral Federal Fundinga
NYC Between
WTC Health 250,000 As of Telephone- Provides Agency for Toxic
9/2004,
Department of
and 400,000 based health information on Substances and
Registry 60,483 people
Health and
responders and interview; plan where Disease Registry
were enrolledb
Mental Hygiene intends to fund
people living to re-interview treatment can through
or
attending subset of be sought; fiscal year 2008
school
in the area of population in refers - $20 million
the total
WTC or working 2005 participants Environmental
to
or being LIFENETc for Protection
present Agency
in the vicinity mental health allocated in
on fiscal year
September 11 services 2004
- $1.5 million
total
FDNY WTC FDNY Bureau About 11,000 As of 4/2004, Medical
Medical of Health firefighters and 11,770 examination
Monitoring Services 3,500 emergency firefighters and and
Program (FDNY-BHS) medical service EMS technicians questionnaire;
(FDNY program) (EMS) were enrolled three follow-up
technicians examinations planned
WTC Worker and Mount Sinai's About 12,000 As of 8/2004, Medical Volunteer
Irving J. responderse about 11,793 examination Medical Selikoff Clinical
people were and Monitoring Center for enrolled questionnaire; Program
Occupational three follow-up (Mount Sinai and examinations program)
Environmental planned
d
Medicine Refers to FDNY-BHS
Refers to privately funded program available for responders National
Institute for Occupational Safety and Health (NIOSH) intends to fund
through 6/2009
- $25 million total National Center for Environmental Health funded
initial monitoring
- $4.8 million total
NIOSH intends to fund through 7/2009
- $56 million total NIOSH funded initial
f
monitoring
- $15.8 million total The medical New York State About 9,800 As of
10/2003, Medical Instructs National Center for monitoring Department of
New York State 1,677 employees examination participants to Environmental
Health program for Health employees and received medical and see their
funded through fiscal New York State National Guard evaluations
questionnaire; primary care year 2003 workers personnel follow-up on
physician or - $2.4 million total (NYS program) subset of 300 the state's
employees occupational planned health unit
WTC cleanup Johns Hopkins About 12,000 As of 6/2003, Mail-in health
Provides National Institute of and recovery Bloomberg members from 1,337
workers survey participants Environmental Health worker registry School of
three unionsg and responded to the with brochures Sciences (NIEHS) (Johns
Hopkins Public Health the NYC mailed about health funded through fiscal
registry) Department of questionnaire services; refers year 2003h
Sanitation uninsured to - $1.2 millioni total Columbia University for
mental health services
Eligible Monitoring Treatment Intended Duration and Administrator
Populations Participation Methods Referral Federal Fundinga
WTC responder Department of About 10,000 As of 3/2004, Medical Instructs
HHS intends to fund
screening Health and federal workers 412 exams were examination
participants to through 12/2005
program for Human responding to completed and and see their - $3.7 million
total
federal workersj Services' WTC reviewed questionnaire primary care
(FOH program) (HHS) Federal physician
Occupational Health services
Sources: FDNY, HHS, Mount Sinai, New York City Department of Health and
Mental Hygiene, and New York State Department of Health.
Note: Programs are ordered according to participation level.
aExcept as noted, FEMA provided funds to the agencies listed below through
interagency agreements with HHS to support efforts to monitor the health
effects of the WTC attack.
bThe WTC Heath Registry officials told us that they have generated a list
of 185,000 potential participants gathered from various sources, including
employers and registration via the Web or telephone. Registry officials
told us that the registry will continue to interview and enroll people who
are on this list after the registration period ends.
cLIFENET is a 24-hour mental health information and referral service
provided by the New York State Office of Mental Health.
dMount Sinai is the coordinating center for the five clinics in this
program.
ePeople eligible to participate in the Mount Sinai program are those who
worked primarily at or immediately adjacent to the WTC site, either during
or after the disaster, including firefighters from outside NYC, police
officers from NYC and surrounding communities, emergency rescue workers
from a variety of organizations (including emergency medical technicians
and paramedics), building and construction trade workers from the NYC
metropolitan area and throughout the nation, members of the press and news
media, health care workers, food service workers, structural and other
engineers, and a variety of other public- and private-sector workers, and
people who worked in the immediate vicinity of the WTC site restoring
essential services, such as telephone services, electricity, and
transportation, or performing services necessary to reopen buildings in
the area, including cleaning and assessing the structural integrity of
nearby buildings. The program excluded federal employees, FDNY
firefighters, and, initially, New York State employees, who were all
eligible for other programs. New York State responders were initially
screened in the NYS program. The NYS program plans to follow 300 of these
responders. All New York State responders are now eligible to participate
in the Mount Sinai program.
fInitial medical monitoring conducted through this program was supported
by funds appropriated to CDC.
gThe International Brotherhood of Teamsters, the International Union of
Operating Engineers, and the Laborers International Union of North
America.
hFunds appropriated to NIEHS to support research, worker training, and
education activities supported this grant.
iIncludes funding for other activities, including Johns Hopkins' WTC
Cleanup and Recovery Worker Health Assessment and community outreach.
jHHS officials told us that HHS is making modifications to the program and
no screenings are taking place.
Program Eligibility
The six programs that have been created to monitor people who were exposed
to the WTC attack and its aftermath vary in terms of populations eligible
to participate. Although five of the programs focus on various responder
populations, the largest program-the WTC Health Registry-is open not only
to responders but also to people living or attending school in the
vicinity of the WTC site, or working or present in the vicinity on
September 11. Specifically, people eligible for participation in the WTC
Health Registry include anyone who was in a building, on the street, or on
the subway south of Chambers Street on September 11; residents and staff
of or students enrolled in schools (prekindergarten through twelfth grade)
or day care centers south of Canal Street on September 11; and those
involved in rescue, recovery, cleanup, or other activities at the WTC site
and/or WTC recovery operations on Staten Island anytime between September
11, 2001, and June 30, 2002. (See figure 1.) An estimated 250,000 to
400,000 people are eligible for the WTC Health Registry23; however, the
registry was planned with the expectation that 100,000 to 200,000 people
would enroll. Together the FDNY program and the Mount Sinai program cover
more than half of the estimated 40,000 WTC responders.24 The FDNY program
is open to all 11,000 FDNY firefighters and all 3,500 FDNY EMS
technicians, including firefighters and technicians who were not exposed.
Some 12,000 other responders are eligible to participate in the Mount
Sinai program. Responders who were government employees are eligible for
participation in programs such as the FOH program, which is open to the
estimated 10,000 federal workers who responded to the WTC attacks, and the
NYS program, which was open to about 9,800 New York State employees and
New York National Guard personnel who were directed to respond to the WTC
disaster. In addition, approximately 12,000 members from three NYC unions
and the NYC Department of Sanitation, whether they were responders or not,
were eligible to participate in the Johns Hopkins registry.
23New York City Department of Health and Mental Hygiene and Department of
Health and Human Services, Agency for Toxic Substances and Disease
Registry, Protocol for the World Trade Center Health Registry (New York,
2003).
24Officials involved in the monitoring efforts acknowledge the potential
for duplication across programs-for example, a responder could be enrolled
in the Mount Sinai program, the Johns Hopkins registry, and the WTC Health
Registry-but they have not determined the extent of duplication.
Figure 1: Map of Lower Manhattan Showing Canal Street, Chambers Street,
and the WTC Site
Source: GAO adaptation based on WTC Health Registry Eligibility Map
provided by New York City Department of Health and Mental Hygiene.
Concerns have been raised by community and labor representatives regarding
the eligibility requirements for some of these programs, and while changes
have been made to accommodate some of these concerns, others remain
unresolved, particularly with respect to the WTC Health Registry. For
example, the eligibility criteria for participation in the Mount Sinai
program were initially more restrictive, covering responders who
had been at the site at least 24 hours between September 11 and 14, 2001.
After discussions with labor representatives and CDC officials, the
program expanded its eligibility criteria to include additional responders
who may not have been there on those days but were there later in
September. In contrast, community and labor representatives have been
unsuccessful in their attempts to expand the eligibility criteria of the
WTC Health Registry. These representatives have noted that the geographic
boundaries used by the registry exclude office workers below Chambers
Street who were not at work on September 11 but returned to work in the
following weeks; office workers, including several groups of city
employees, working between Chambers and Canal Streets; and Brooklyn
residents who may have been exposed to the cloud of dust and smoke.
Registry officials told us that they understand the desire to be included
but they believe coverage is adequate to provide a basis for understanding
the health effects of the WTC attack.
Monitoring Methods and Options for Treatment Referral
The monitoring programs vary in their methods for identifying those who
may require treatment, and although none of these programs are funded to
provide treatment, they provide varying options for treatment referral.
Some programs refer participants to affiliated treatment programs, whereas
others provide information on where participants can seek care. The FDNY
program offers a comprehensive medical evaluation that includes collection
of blood and urine for analysis, a pulmonary function test, a chest X-ray,
a renal toxicity evaluation, a cardiogram, a hepatitis C test, and hearing
and vision tests, as well as self-administered questionnaires on exposures
and physical and mental health. Funds for the monitoring program do not
cover treatment services. However, FDNY members who require treatment
after being screened can obtain treatment and counseling services from the
FDNY Bureau of Health Services and the FDNY Counseling Services Unit as a
benefit of their employment. Similarly, under the Mount Sinai program,
people receive a comprehensive physical examination that includes blood
and urine analysis, a chest X-ray, a pulmonary function test, and complete
self-administered as well as nurse-administered questionnaires on
exposure, clinical history, and mental health.25 If a person requires
follow-up medical care or mental health services but is unable to pay for
the services, he or she can be
25In addition, a standardized evaluation of nasal passages and upper
airways is performed on a subgroup of 1,000 participants.
referred for care to other Mount Sinai programs such as the Health for
Heroes program, which is supported through philanthropic donations.
The FOH and NYS programs also consist of medical evaluations of
participants and self-administered health and exposure questionnaires. The
FOH program conducted about 400 medical evaluations of federal workers.
These evaluations included a physical examination, a pulmonary function
test, a chest X-ray, and blood tests. Under the NYS program, the New York
State Department of Civil Service Employee Health Service clinics or
affiliated clinics conducted medical evaluations that included a physical
examination and a pulmonary evaluation of almost 1,700 state workers. The
questionnaires for both programs are more limited than the FDNY or Mount
Sinai questionnaires; for example, they have fewer mental health
questions. Under the FOH and NYS programs, workers who require care have
been told to follow up with their primary care physicians under their own
insurance.
Unlike most of the other monitoring programs, the WTC Health Registry and
the Johns Hopkins registry do not include a medical evaluation, and
neither effort is affiliated with a treatment facility or program.
Instead, the programs collect information from participants solely through
questionnaires and provide information on where participants can seek
care. The WTC Health Registry questionnaire is generally administered over
the telephone. The program provides all participants with a resource guide
of occupational, respiratory, environmental, and mental health facilities
in New York State, New Jersey, and Connecticut where people can seek
treatment. Some of the services provided by these facilities require
health insurance, whereas others are free of charge. If in the course of a
telephone questionnaire, a person's responses to the mental health
questions suggest that he or she may need to speak with a mental health
professional, the person is given the option of being connected directly
to a LIFENET counselor. The LIFENET counselor provides the person with
information on where to go and whom to call for help with problems related
to the WTC disaster. For the Johns Hopkins registry, the participants
complete a mail-in questionnaire on physical and mental health. Responders
who report mental health symptoms and agree to be recontacted may receive
follow-up calls to refer them to mental health services. The referral
process is facilitated by Columbia University's Resiliency Program, which
provides free, short-term mental health services to affected people. The
Johns Hopkins registry also provides participants with brochures about
health services and programs they may find useful, including information
about the Mount Sinai program.
Duration and Funding
The duration of the monitoring programs may not be long enough to fully
capture critical information on health effects. Under current plans, HHS
funding for the programs will not extend beyond 2009. For example, ATSDR
entered into a cooperative agreement with the New York City Department of
Health and Mental Hygiene in fiscal year 2003 with the intent to continue
support of the WTC Health Registry for 5 years of its planned 20-year
duration. Similarly, NIOSH awarded 5-year grants in July 2004 to continue
the FDNY and Mount Sinai programs, which had begun in 2001 and 2002,
respectively. Health experts involved in the monitoring programs, however,
cite the need for long-term monitoring of affected groups because some
possible health effects, such as cancer, do not appear until several
decades after a person has been exposed to a harmful agent.26 They also
emphasize that monitoring is important for identifying and assessing the
occurrence of newly identified conditions, such as WTC cough, and chronic
conditions, such as asthma.
Collaboration
Although the monitoring programs began as separate efforts, some of the
programs are collaborating with each other. In addition, there are other
kinds of collaborative efforts, including those in which programs receive
advice from various outside partners.
The WTC Responder Health Consortium is an example of collaboration between
monitoring programs. It was established by NIOSH in March 2004 to
coordinate the existing health monitoring of WTC responders initiated by
the FDNY and Mount Sinai programs and to facilitate data sharing. It
awarded $81 million in 5-year grants to six institutions to become
clinical centers for WTC health monitoring. FDNY and Mount Sinai serve as
coordinating centers under the consortium, and the other four institutions
are coordinated with Mount Sinai.27 Together, these institutions will
26For example, symptoms of lung cancer may not appear for decades after
exposure.
27These four institutions are the Long Island Occupational and
Environmental Health Center, the New York University School of Medicine,
the City University of New York's Queens College, and the University of
Medicine and Dentistry of New Jersey's Robert Wood Johnson Medical School.
provide follow-up health evaluations to a total of about 12,000 NYC
firefighters and EMS technicians and up to 12,000 other WTC responders.28
Collaboration efforts have also been fostered between the monitoring
programs and outside partners and researchers. For example, the WTC
Registry has a Scientific Advisory Group that includes representatives
from the Mount Sinai School of Medicine, FDNY, the Johns Hopkins
University, Columbia University, Hunter College, New York Academy of
Medicine, New York University, the New York State Department of Health,
and the New Jersey Department of Health. The group has assisted the New
York City Department of Health and Mental Hygiene and ASTDR in development
of the WTC Registry protocol, selection of the eligible population, and
analysis methods. It has been meeting with WTC officials quarterly since
early 2002 to advise on such issues as data collection, study options, and
guidelines for research studies to be done using the registry.
In addition, EPA convened an expert review panel in March 2004 to obtain
greater input on ongoing efforts to monitor the health effects of workers
and residents affected by the WTC collapse. The panel consists of
representatives from federal and NYC agencies involved in air monitoring;
from WTC health effects monitoring programs; and from academic
institutions and the affected community. The goals of the panel include
identification of unmet public health needs, gaps in exposure data, gaps
in efforts to understand the health effects of the WTC attack, and ways in
which the WTC Health Registry could be enhanced to allow better tracking
of workers and residents.
A multitude of physical and mental health effects have been reported in
the years since the terrorist attack on the World Trade Center on
September 11, 2001, but the full health impact of the attack is unknown.
Concern about potential long-term effects on people affected by the attack
remains. The monitoring programs may not be in operation long enough to
adequately capture information about new conditions, chronic conditions,
and diseases whose onset may occur decades after exposure to a harmful
agent, such as many cancers. Nevertheless, these programs are providing a
more complete picture of the health impact of such events, and as they
28NYPD also applied to be in the consortium to provide monitoring for its
officers who were responders to the WTC disaster, but was not able to
secure funding to support its monitoring activities. However, NYPD
responders are eligible for enrollment in the Mount Sinai program.
Concluding Observations
Agency Comments
proceed they are also providing the opportunity to identify people needing
treatment.
We provided a draft of this testimony to DHS, DOL, EPA, and HHS. HHS
provided written comments, in which it noted that the testimony does not
include significant discussion on the ways in which mental health symptoms
have changed over time. We relied primarily on data from published,
peer-reviewed articles and government reports, and some of the researchers
we spoke with emphasized that their studies are ongoing and they expect to
publish further results. In the absence of these results, the evidence we
examined did not support a full discussion of changes in mental or
physical health effects over time. HHS and the other agencies also
provided technical comments, which we incorporated as appropriate.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other members of the Subcommittee may have
at this time.
Contact and Staff For further information about this testimony, please
contact Janet Heinrich at (202) 512-7119. Michele Orza, Angela Choy, Alice
London,
Acknowledgments Nkeruka Okonmah, and Roseanne Price made key
contributions to this statement.
Appendix I: Abbreviations
ATSDR Agency for Toxic Substances and Disease Registry
CDC Centers for Disease Control and Prevention
DOD Department of Defense
DHS Department of Homeland Security
DOJ Department of Justice
DOL Department of Labor
DMAT Disaster Medical Assistance Teams
EMS emergency medical services
EPA Environmental Protection Agency
FBI Federal Bureau of Investigation
FEMA Federal Emergency Management Agency
FOH Federal Occupational Health
FDNY New York City Fire Department
GERD gastroesophageal reflux disease
HHS Department of Health and Human Services
NIEHS National Institute of Environmental Health Sciences
NIOSH National Institute for Occupational Safety and Health
NYC New York City
NYPD New York City Police Department
OSHA Occupational Safety and Health Administration
PTSD posttraumatic stress disorder
SGA small for gestational age
SAMHSA Substance Abuse and Mental Health Services
Administration VA Department of Veterans Affairs WTC World Trade Center
Bibliography
Banauch, G.I., et al. "Persistent Hyperreactivity and Reactive Airway
Dysfunction in Firefighters at the World Trade Center." American Journal
of Respiratory and Critical Care Medicine, 168, no. 1 (2003): 54-62.
Berkowitz, G.S., et al. "The World Trade Center Disaster and Intrauterine
Growth Restriction." (Letter) Journal of the American Medical Association,
290, no. 5 (2003): 595-96.
Berrios-Torres, S.I., et al. "World Trade Center Rescue Worker Injury and
Illness Surveillance, New York, 2001." American Journal of Preventive
Medicine, 25, no. 2 (2003): 79-87.
Boscarino, J.A., et al. "Mental Health Service and Medication Use in New
York City after the September 11, 2001, Terrorist Attack." Psychiatric
Services, 55, no. 3 (2004): 274-83.
Boscarino, J.A., et al. "Psychiatric Medication Use among Manhattan
Residents Following the World Trade Center Disaster." Journal of Traumatic
Stress, 16, no. 3 (2003): 301-6.
Centers for Disease Control and Prevention. "Injuries and Illnesses among
New York City Fire Department Rescue Workers after Responding to the World
Trade Center Attacks." Special Issue, Morbidity and Mortality Weekly
Report, 51 (2002a): 1-13.
Centers for Disease Control and Prevention. "Psychological and Emotional
Effects of the September 11 Attacks on the World Trade Center-
Connecticut, New Jersey, and New York, 2001." Morbidity and Mortality
Weekly Report, 51, no. 35 (2002b): 784-85.
Centers for Disease Control and Prevention. "Rapid Assessment of Injuries
among Survivors of the Terrorist Attack on the World Trade Center-New York
City, September 2001." Morbidity and Mortality Weekly Report, 51, no. 1
(2002c): 1-5.
Chi, J.S., et al. "Hospital Admissions for Cardiac Events in New York City
after September 11, 2001." American Journal of Cardiology, 92, no. 1
(2003): 61-63.
Cushman, J.G., et al. "Two New York City Hospitals' Surgical Response to
the September 11, 2001, Terrorist Attack in New York City." Journal of
Trauma, 54, no. 1 (2003): 147-55.
DeLisi, L.E., et al. "A Survey of New Yorkers after the Sept. 11, 2001,
Terrorist Attacks." American Journal of Psychiatry, 160, no. 4 (2003):
780-83.
Deren, S., et al. "Impact of the September 11th Attacks in New York City
on Drug Users: A Preliminary Assessment." Journal of Urban Health:
Bulletin of the New York Academy of Medicine, 79, no. 3 (2002): 409-12.
Edelman, P., et al. "Biomonitoring of Chemical Exposure among New York
City Firefighters Responding to the World Trade Center Fire and Collapse."
Environmental Health Perspectives, 111, no. 16 (2003): 1906-11.
Fairbrother, G., et al. "Posttraumatic Stress Reactions in New York City
Children after the September 11, 2001, Terrorist Attacks." Ambulatory
Pediatrics, 3, no. 6. (2003): 304-11.
Feldman, D.M., et al. "Symptoms, Respirator Use, and Pulmonary Function
Changes among New York City Firefighters Responding to the World Trade
Center Disaster." Chest, 125, no. 4 (2004): 1256-64.
Galea, S., et al. "Posttraumatic Stress Disorder in Manhattan, New York
City, after the September 11th Terrorist Attacks." Journal of Urban
Health: Bulletin of the New York Academy of Medicine, 79, no. 3 (2002a):
340-53.
Galea, S., et al. "Psychological Sequelae of the September 11 Terrorist
Attacks in New York City." New England Journal of Medicine, 346, no. 13
(2002b): 982-87.
Galea, S., et al. "Trends of Probable Post-Traumatic Stress Disorder in
New York City after the September 11 Terrorist Attacks." American Journal
of Epidemiology, 158, no. 6 (2003): 514-24.
Greater New York Hospital Association. GNYHA Survey on the Utilization of
Hospital-Based Psychiatric Services Following the Attack on the World
Trade Center: A Final Report. New York, 2001.
Herbert, R., and S. Levin. World Trade Center Worker and Volunteer Medical
Screening Program. Report of Initial Findings to the National Institute
for Occupational Safety and Health of the Centers for Disease Control and
Prevention. New York, 2003.
Hoven, C.W., et al. "Mental Health of New York City Public School Children
after 9/11: An Epidemiologic Investigation." In S. Coates et al. (eds.),
September 11: Trauma and Human Bonds. Hillsdale, NJ: Analytic Press, 2003.
Landrigan, P.J., et al. "Health and Environmental Consequences of the
World Trade Center Disaster." Environmental Health Perspectives, 112, no.
6 (2004): 731-39.
Levin, S., et al. "Health Effects of World Trade Center Site Workers."
American Journal of Industrial Medicine, 42, no. 6 (2002): 545-47.
Levy, B.S., and V.W. Sidel (eds.). Terrorism and Public Health. New York:
Oxford University Press, 2003.
Lippy, B.E. "Safety and Health of Heavy Equipment Operators at Ground
Zero." American Journal of Industrial Medicine, 42, no. 6 (2002): 539-42.
Malievskaya, E., et al. "Assessing the Health of Immigrant Workers near
Ground Zero: Preliminary Results of the World Trade Center Day Laborer
Medical Monitoring Project." American Journal of Industrial Medicine, 42,
no. 6 (2002): 548-49.
Martyny, J., et al. "Respiratory Protection." New England Journal of
Medicine, 347, no. 11 (2002): 824-30.
Niles, B.L., et al. "Posttraumatic Stress Disorder Symptomatology in
Vietnam Veterans before and after September 11." Journal of Nervous and
Mental Disease, 191, no. 10 (2003): 682-84.
Prezant, D.J., et al. "Cough and Bronchial Responsiveness in Firefighters
at the World Trade Center Site." New England Journal of Medicine, 347, no.
11 (2002): 806-15.
Rom, W.N., et al. "Acute Eosinophilic Pneumonia in a New York City
Firefighter Exposed to World Trade Center Dust." American Journal of
Respiratory and Critical Care Medicine, 166, no. 6 (2002): 797-800.
Rosenheck, R.A., and A. Fontana. "Post-September 11 Admission Symptoms and
Treatment Response among Veterans with Posttraumatic Stress Disorder."
Psychiatric Services, 54, no. 12 (2003): 1610-17.
Salzman, S.H., et al. "Early Respiratory Abnormalities in Emergency
Services Police Officers at the World Trade Center Site." Journal of
Occupational and Environmental Medicine, 46, no. 2 (2004): 113-22.
Schlenger, W.E., et al. "Psychological Reactions to Terrorist Attacks:
Findings from the National Study of Americans' Reactions to September 11."
Journal of the American Medical Association, 288, no. 5 (2002): 581-88.
Schuster, M.A., et al. "A National Survey of Stress Reactions after the
September 11, 2001, Terrorist Attacks." New England Journal of Medicine,
345, no. 20 (2001): 1507-12.
Silver, R.C., et al. "Nationwide Longitudinal Study of Psychological
Responses to September 11." Journal of the American Medical Association,
288, no. 10 (2002): 1235-44.
Simeon, D., et al. "Peritraumatic Reactions Associated with the World
Trade Center Disaster." American Journal of Psychiatry, 160, no. 9 (2003):
1702-5.
Skloot, G., et al. "Respiratory Symptoms and Physiologic Assessment of
Ironworkers at the World Trade Center Disaster Site." Chest, 125, no. 4
(2004): 1248-55.
Spadafora, R. "Firefighter Safety and Health Issues at the World Trade
Center Site." American Journal of Industrial Medicine, 42, no. 6 (2002):
532-38.
Szema, A.M., et al. "Clinical Deterioration in Pediatric Asthmatic
Patients after September 11, 2001." Journal of Allergy and Clinical
Immunology, 113, no. 3 (2004): 420-26.
Thiel de Bocanegra, H., and E. Brickman. "Mental Health Impact of the
World Trade Center Attacks on Displaced Chinese Workers." Journal of
Traumatic Stress, 17, no. 1 (2004): 55-62.
Trout, D., et al. "Health Effects and Occupational Exposures among Office
Workers near the World Trade Center Disaster Site." Journal of
Occupational and Environmental Medicine, 44, no. 7 (2002): 601-5.
Vlahov, D., et al. "Increased Use of Cigarettes, Alcohol, and Marijuana
among Manhattan, New York, Residents after the September 11th Terrorist
Attacks." American Journal of Epidemiology, 155, no. 11 (2002): 988-96.
Vlahov, D., et al. "Consumption of Cigarettes, Alcohol, and Marijuana
among New York City Residents Six Months after the September 11 Terrorist
Attacks." American Journal of Drug and Alcohol Abuse, 30, no. 2 (2004a):
385-407.
Vlahov, D., et al. "Sustained Increased Consumption of Cigarettes,
Alcohol, and Marijuana among Manhattan Residents after September 11,
2001." American Journal of Public Health, 94, no. 2 (2004b): 253-4.
Wallingford, K.M., and E.M. Snyder. "Occupational Exposures during the
World Trade Center Disaster Response." Toxicology and Industrial Health,
17, no. 5-10 (2001): 247-53.
Warren, T., et al. "Factors Influencing Experienced Distress and Attitude
toward Trauma by Emergency Medicine Practitioners." Journal of Clinical
Psychology in Medical Settings, 10, no. 4 (2003): 293-96.
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