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9/11 Health Update

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Global Health".

Deadline for manuscript submissions: closed (31 December 2020) | Viewed by 53672

Special Issue Editors

Dr. James Cone

E-Mail Website
Guest Editor
New York City Department of Health and Mental Hygiene
Interests: Occupational / Environmental Medicine;Disaster Epidemiology;Public Health Surveillance
Dr. Albeliz Santiago-Colón

E-Mail
Co-Guest Editor
Technical Analyst, World Trade Center Health Program
Interests: Occupational/Environmental Health; Maternal and Child Health; Reproductive Health
Prof. Roberto Lucchini

E-Mail Website
Co-Guest Editor
School of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
Interests: Cognitive Neuroscience; Imaging; MRI; Magnetic Resonance Imaging; Memory; Neurotoxicology; Parkinson's Disease

Special Issue Information

Dear Colleagues,

A Topical Collection on 9/11 health, in the International Journal of Environmental Research and Public Health, is being organized. For detailed information on the journal, I refer you to https://0-www-mdpi-com.brum.beds.ac.uk/journal/ijerph).  The 9/11 World Trade Center disaster exposed hundreds of thousands of area workers, residents, students, and school staff (survivors) and rescue and recovery workers (responders) to acute trauma, as well as a complex mixture of dust, gases, and debris from the collapse and intense psychological stress. Researchers and clinicians have been looking to better understand the immediate and long-term consequences of the disaster to help identify interventions to decrease the future impact of this event. This Topical Collection is open for submission of manuscripts on the subject area of 9/11 health. The keywords below provide an outline of some of the possible areas of interest.

Dr. James Cone
Prof. Roberto Lucchini
Dr. Abeliz Santiago-Colon
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • long term complications of 9/11 exposure
  • living with PTSD
  • epidemiology
  • multi-morbidity
  • risk factors
  • special populations—children, adolescents, new adults, elderly and 9/11
  • emerging medical conditions
  • interventions to reduce the burden of 9/11-related disease
  • 9/11
  • World Trade Center
  • Disaster Epidemiology
  • PTSD.

Published Papers (18 papers)

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Editorial

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5 pages, 281 KiB  
Editorial
9/11 Health Update
by James E. Cone, Albeliz Santiago-Colón and Roberto Lucchini
Int. J. Environ. Res. Public Health 2021, 18(12), 6383; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18126383 - 12 Jun 2021
Viewed by 3443
Abstract
This Special Issue of the International Journal of Environmental Research and Public Health is dedicated to increasing the scientific information available about the long-term effects of exposure to the 2001 World Trade Center disaster [...] Full article
(This article belongs to the Special Issue 9/11 Health Update)

Research

Jump to: Editorial, Review, Other

14 pages, 651 KiB  
Article
Lung Cancer Characteristics in the World Trade Center Environmental Health Center
by Nedim Durmus, Sultan Pehlivan, Yian Zhang, Yongzhao Shao, Alan A. Arslan, Rachel Corona, Ian Henderson, Daniel H. Sterman and Joan Reibman
Int. J. Environ. Res. Public Health 2021, 18(5), 2689; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18052689 - 07 Mar 2021
Cited by 7 | Viewed by 2419
Abstract
The destruction of the World Trade Center (WTC) towers on 11 September 2001 resulted in acute and chronic dust and fume exposures to community members, including local workers and residents, with well-described aerodigestive adverse health effects. This study aimed to characterize lung cancer [...] Read more.
The destruction of the World Trade Center (WTC) towers on 11 September 2001 resulted in acute and chronic dust and fume exposures to community members, including local workers and residents, with well-described aerodigestive adverse health effects. This study aimed to characterize lung cancer in the WTC Environmental Health Center (WTC EHC) focusing on gender and smoking history. WTC EHC patients undergo an initial evaluation that includes WTC exposure information, demographics, and tobacco use. Detailed cancer characteristics are recorded from pathology reports. As of 31 December 2019, 248 WTC EHC patients had a diagnosis of lung cancer. More patients with lung cancer were women (57%) compared to men (43%). Many cases (47% women, 51% men) reported acute dust cloud exposure. Thirty-seven percent of lung cancer cases with available smoking history were never-smokers (≤1 pack-years) and 42% had a ≤5 pack-year history. The median age of cancer diagnosis in never-smoking women was 61 years compared to 66 years in men. Adenocarcinoma was more common in never-smokers compared to ever-smokers (72% vs. 65%) and in women compared to men (70% vs. 65%). We provide an initial description of lung cancers in local community members with documented exposure to the WTC dust and fumes. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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18 pages, 1444 KiB  
Article
Impact of World Trade Center-Related Health Research: An Application of the NIEHS Translational Framework
by Jaime Madrigano, Thomas W. Concannon, Sean Mann, Sameer M. Siddiqi, Ramya Chari and Laura J. Faherty
Int. J. Environ. Res. Public Health 2021, 18(5), 2659; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18052659 - 06 Mar 2021
Cited by 1 | Viewed by 2263
Abstract
The World Trade Center Health Program (WTCHP) has a research mission to identify physical and mental health conditions that may be related to the 9/11 terrorist attacks as well as effective diagnostic procedures and treatments for WTC-related health conditions. The ability of the [...] Read more.
The World Trade Center Health Program (WTCHP) has a research mission to identify physical and mental health conditions that may be related to the 9/11 terrorist attacks as well as effective diagnostic procedures and treatments for WTC-related health conditions. The ability of the WTCHP to serve its members and realize positive impacts on all of its stakeholders depends on effective translation of research findings. As part of an ongoing assessment of the translational impact of World Trade Center (WTC)-related research, we applied the National Institute of Environmental Health Sciences (NIEHS) translational framework to two case studies: WTC-related research on post-traumatic stress disorder (PTSD) and cancer. We conducted a review of 9/11 health-related research in the peer-reviewed literature through October 2017, grey literature, and WTCHP program documentation. We mapped peer-reviewed studies in the literature to the NIEHS framework and used WTCHP program documentation and grey literature to find evidence of translation of research into clinical practice and policy. Using the NIEHS framework, we identified numerous translational milestones and bridges, as well as areas of opportunity, within each case study. This application demonstrates the utility of the NIEHS framework for documenting progress toward public health impact and for setting future research goals. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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18 pages, 1102 KiB  
Article
The Development of a WTC Environmental Health Center Pan-Cancer Database
by Yongzhao Shao, Nedim Durmus, Yian Zhang, Sultan Pehlivan, Maria-Elena Fernandez-Beros, Lisette Umana, Rachel Corona, Adrienne Addessi, Sharon A. Abbott, Sheila Smyth-Giambanco, Alan A. Arslan and Joan Reibman
Int. J. Environ. Res. Public Health 2021, 18(4), 1646; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18041646 - 09 Feb 2021
Cited by 14 | Viewed by 2530
Abstract
(1) Background: Recent studies have reported elevated risks of multiple cancers in the World Trade Center (WTC) affected community members (also called WTC “Survivors”). The large variety of WTC-cancers created a need to develop a comprehensive cancer database. This paper describes the development [...] Read more.
(1) Background: Recent studies have reported elevated risks of multiple cancers in the World Trade Center (WTC) affected community members (also called WTC “Survivors”). The large variety of WTC-cancers created a need to develop a comprehensive cancer database. This paper describes the development of a pan-cancer database at the WTC Environmental Health Center (EHC) Data Center. (2) Methods: A new REDCap-based pan-cancer database was created using the pathology reports and available biomarker data of confirmed cancer cases after review by a cancer epidemiologist, a pathologist, physicians and biostatisticians. (3) Results: The WTC EHC pan-cancer database contains cancer characteristics and emerging biomarker information for cancers of individuals enrolled in the WTC EHC and diagnosed after 11 September 2001 and up to 31 December 2019 obtained from WTC EHC clinical records, pathological reports and state cancer registries. As of 31 December 2019, the database included 3440 cancer cases with cancer characteristics and biomarker information. (4) Conclusions: This evolving database represents an important resource for the scientific community facilitating future research about the etiology, heterogeneity, characteristics and outcomes of cancers and comorbid mental health conditions, cancer economics and gene–environment interaction in the unique population of WTC survivors. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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11 pages, 347 KiB  
Article
World Trade Center Exposure and Posttraumatic Growth: Assessing Positive Psychological Change 15 Years after 9/11
by Cristina D. Pollari, Jennifer Brite, Robert M. Brackbill, Lisa M. Gargano, Shane W. Adams, Pninit Russo-Netzer, Jonathan Davidov, Victoria Banyard and James E. Cone
Int. J. Environ. Res. Public Health 2021, 18(1), 104; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18010104 - 25 Dec 2020
Cited by 12 | Viewed by 2849
Abstract
We evaluated the presence of posttraumatic growth (PTG) among survivors of the 9/11 terrorist attack and how indicators of psychosocial well-being, direct 9/11-related exposure, and posttraumatic stress symptoms (PTSS) relate to PTG. PTG was examined among 4934 participants using the Posttraumatic Growth Inventory [...] Read more.
We evaluated the presence of posttraumatic growth (PTG) among survivors of the 9/11 terrorist attack and how indicators of psychosocial well-being, direct 9/11-related exposure, and posttraumatic stress symptoms (PTSS) relate to PTG. PTG was examined among 4934 participants using the Posttraumatic Growth Inventory (PTGI). A confirmatory factor analysis (CFA) was conducted to determine if the original factor structure of the PTGI fits our data and principal component analysis (PCA) to identify the appropriate factor structure. Multivariable linear regression models were used to examine the association between PTG and indicators of psychosocial well-being, 9/11-related exposure, and PTSS, controlling for covariates. CFA identified a two-factor structure of the PTGI as a better fit than the original five-factor model. Participants who experienced very high 9/11-related exposure level (ß = 7.72; 95% CI: 5.75–9.70), higher PTSS at waves 1 (ß = 0.13; 95% CI: 0.08–0.18) and 2 (ß = 0.09; 95% CI: 0.05–0.14), high social integration (ß = 5.71; 95% CI: 4.47, 6.96), greater social support (ß = 0.49; 95% CI: 0.37, 0.61), and higher self-efficacy (ß = 1.26; 95% CI: 1.04, 1.48) had higher PTGI scores. Our findings suggest PTG is present, 15 years following the 9/11 terrorist attack. Very high-level 9/11 exposure, PTSS, and indicators of psychosocial well-being were associated with PTG. Full article
(This article belongs to the Special Issue 9/11 Health Update)
11 pages, 1179 KiB  
Article
Factors Predicting Treatment of World Trade Center-Related Lung Injury: A Longitudinal Cohort Study
by Barbara Putman, Lies Lahousse, David G. Goldfarb, Rachel Zeig-Owens, Theresa Schwartz, Ankura Singh, Brandon Vaeth, Charles B. Hall, Elizabeth A. Lancet, Mayris P. Webber, Hillel W. Cohen, David J. Prezant and Michael D. Weiden
Int. J. Environ. Res. Public Health 2020, 17(23), 9056; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17239056 - 04 Dec 2020
Cited by 3 | Viewed by 1927
Abstract
The factors that predict treatment of lung injury in occupational cohorts are poorly defined. We aimed to identify patient characteristics associated with initiation of treatment with inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) >2 years among World Trade Center (WTC)-exposed firefighters. The study population included 8530 [...] Read more.
The factors that predict treatment of lung injury in occupational cohorts are poorly defined. We aimed to identify patient characteristics associated with initiation of treatment with inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) >2 years among World Trade Center (WTC)-exposed firefighters. The study population included 8530 WTC-exposed firefighters. Multivariable logistic regression assessed the association of patient characteristics with ICS/LABA treatment for >2 years over two-year intervals from 11 September 2001–10 September 2017. Cox proportional hazards models measured the association of high probability of ICS/LABA initiation with actual ICS/LABA initiation in subsequent intervals. Between 11 September 2001–1 July 2018, 1629/8530 (19.1%) firefighters initiated ICS/LABA treatment for >2 years. Forced Expiratory Volume in 1 s (FEV1), wheeze, and dyspnea were consistently and independently associated with ICS/LABA treatment. High-intensity WTC exposure was associated with ICS/LABA between 11 September 2001–10 September 2003. The 10th percentile of risk for ICS/LABA between 11 September 2005–10 Septmeber 2007 was associated with a 3.32-fold increased hazard of actual ICS/LABA initiation in the subsequent 4 years. In firefighters with WTC exposure, FEV1, wheeze, and dyspnea were independently associated with prolonged ICS/LABA treatment. A high risk for treatment was identifiable from routine monitoring exam results years before treatment initiation. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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11 pages, 426 KiB  
Article
Post-9/11 Mental Health Comorbidity Predicts Self-Reported Confusion or Memory Loss in World Trade Center Health Registry Enrollees
by Howard E. Alper, Rifat A. Tuly, Kacie Seil and Jennifer Brite
Int. J. Environ. Res. Public Health 2020, 17(19), 7330; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17197330 - 08 Oct 2020
Cited by 9 | Viewed by 2884
Abstract
Numerous studies report elevated levels of chronic mental health conditions in those exposed to the World Trade Center attacks of 11 September 2001 (9/11), but few studies have examined the incidence of confusion or memory loss (CML) or its association with mental health [...] Read more.
Numerous studies report elevated levels of chronic mental health conditions in those exposed to the World Trade Center attacks of 11 September 2001 (9/11), but few studies have examined the incidence of confusion or memory loss (CML) or its association with mental health in 9/11 attack survivors. We investigated the incidence of CML and its association with the number of post-9/11 mental health conditions (PTSD, depression, and anxiety) in 10,766 World Trade Center Health Registry (Registry) enrollees aged 35–64 at the time of the wave 4 survey (2015–2016) that completed all four-wave surveys and met the study inclusion criteria. We employed log-binomial regression to evaluate the associations between CML and the number of mental health conditions. A total of 20.2% of enrollees in the sample reported CML, and there was a dose-response relationship between CML and the number of mental health conditions (one condition: RR = 1.85, 95% CI (1.65, 2.09); two conditions: RR = 2.13, 95% CI (1.85, 2.45); three conditions: RR = 2.51, 95% CI (2.17, 2.91)). Survivors may be experiencing confusion or memory loss partly due to the mental health consequences of the 9/11 attacks. Clinicians treating patients with mental health conditions should be aware of potential cognitive impairment. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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15 pages, 1637 KiB  
Article
Characteristics of Cancer Patients in the World Trade Center Environmental Health Center
by Nedim Durmus, Yongzhao Shao, Alan A. Arslan, Yian Zhang, Sultan Pehlivan, Maria-Elena Fernandez-Beros, Lisette Umana, Rachel Corona, Sheila Smyth-Giambanco, Sharon A. Abbott and Joan Reibman
Int. J. Environ. Res. Public Health 2020, 17(19), 7190; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17197190 - 01 Oct 2020
Cited by 15 | Viewed by 2574
Abstract
The destruction of the World Trade Center (WTC) towers on 11 September 2001 released many tons of aerosolized dust and smoke with potential for carcinogenic exposures to community members as well as responders. The WTC Environmental Health Center (WTC EHC) is a surveillance [...] Read more.
The destruction of the World Trade Center (WTC) towers on 11 September 2001 released many tons of aerosolized dust and smoke with potential for carcinogenic exposures to community members as well as responders. The WTC Environmental Health Center (WTC EHC) is a surveillance and treatment program for a diverse population of community members (“Survivors”), including local residents and workers, present in the NYC disaster area on 9/11 or in the days or weeks following. We report a case series of cancers identified in the WTC EHC as of 31 December 2019. Descriptive characteristics are presented for 2561 cancer patients (excluding non-melanoma skin cancer) and 5377 non-cancer WTC-EHC participants who signed informed consent. We identified a total of 2999 cancer diagnoses in 2561 patients: 2534 solid tumors (84.5%) and 465 lymphoid and hematopoietic tissue cancers (15.5%) with forty-one different cancer types. We describe the distribution, frequency, median age of cancer diagnosis and median latency from 9/11 by cancer site. In addition to common cancer types, rare cancers, including male breast cancers and mesotheliomas have been identified. The current study is the first report on cancer characteristics of enrollees at WTC EHC, a federally designated treatment and surveillance program for local community members affected by the 9/11 terrorist attack on the WTC. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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17 pages, 488 KiB  
Article
Characterization of Persistent Uncontrolled Asthma Symptoms in Community Members Exposed to World Trade Center Dust and Fumes
by Joan Reibman, Caralee Caplan-Shaw, Yinxiang Wu, Mengling Liu, Milan R. Amin, Kenneth I. Berger, Maria L. Cotrina-Vidal, Angeliki Kazeros, Nedim Durmus, Maria-Elena Fernandez-Beros, Roberta M. Goldring, Rebecca Rosen and Yongzhao Shao
Int. J. Environ. Res. Public Health 2020, 17(18), 6645; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17186645 - 11 Sep 2020
Cited by 7 | Viewed by 2112
Abstract
The destruction of the World Trade Center (WTC) towers on the 11th of September, 2001 released a vast amount of aerosolized dust and smoke resulting in acute and chronic exposures to community members as well as responders. The WTC Environmental Health Center (WTC [...] Read more.
The destruction of the World Trade Center (WTC) towers on the 11th of September, 2001 released a vast amount of aerosolized dust and smoke resulting in acute and chronic exposures to community members as well as responders. The WTC Environmental Health Center (WTC EHC) is a surveillance and treatment program for a diverse population of community members, including local residents and local workers with WTC dust exposure. Many of these patients have reported persistent lower respiratory symptoms (LRS) despite treatment for presumed asthma. Our goal was to identify conditions associated with persistent uncontrolled LRS despite standard asthma management. We recruited 60 patients who were uncontrolled at enrollment and, after a three-month run-in period on high-dose inhaled corticosteroid and long acting bronchodilator, reassessed their status as Uncontrolled or Controlled based on a score from the Asthma Control Test (ACT). Despite this treatment, only 11 participants (18%) gained Controlled status as defined by the ACT. We compared conditions associated with Uncontrolled and Controlled status. Those with Uncontrolled symptoms had higher rates of upper airway symptoms. Many patients had persistent bronchial hyper-reactivity (BHR) and upper airway hyper-reactivity as measured by paradoxical vocal fold movement (PVFM). We found a significant increasing trend in the percentage of Controlled with respect to the presence of BHR and PVFM. We were unable to identify significant differences in lung function or inflammatory markers in this small group. Our findings suggest persistent upper and lower airway hyper-reactivity that may respond to standard asthma treatment, whereas others with persistent LRS necessitate additional diagnostic evaluation, including a focus on the upper airway. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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15 pages, 911 KiB  
Article
Food Intake REstriction for Health OUtcome Support and Education (FIREHOUSE) Protocol: A Randomized Clinical Trial
by Sophia Kwon, Jessica Riggs, George Crowley, Rachel Lam, Isabel R. Young, Christine Nayar, Maria Sunseri, Mena Mikhail, Dean Ostrofsky, Arul Veerappan, Rachel Zeig-Owens, Theresa Schwartz, Hilary Colbeth, Mengling Liu, Mary Lou Pompeii, David St-Jules, David J. Prezant, Mary Ann Sevick and Anna Nolan
Int. J. Environ. Res. Public Health 2020, 17(18), 6569; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17186569 - 09 Sep 2020
Cited by 4 | Viewed by 3108
Abstract
Fire Department of New York (FDNY) rescue and recovery workers exposed to World Trade Center (WTC) particulates suffered loss of forced expiratory volume in 1 s (FEV1). Metabolic Syndrome increased the risk of developing WTC-lung injury (WTC-LI). We aim to [...] Read more.
Fire Department of New York (FDNY) rescue and recovery workers exposed to World Trade Center (WTC) particulates suffered loss of forced expiratory volume in 1 s (FEV1). Metabolic Syndrome increased the risk of developing WTC-lung injury (WTC-LI). We aim to attenuate the deleterious effects of WTC exposure through a dietary intervention targeting these clinically relevant disease modifiers. We hypothesize that a calorie-restricted Mediterranean dietary intervention will improve metabolic risk, subclinical indicators of cardiopulmonary disease, quality of life, and lung function in firefighters with WTC-LI. To assess our hypothesis, we developed the Food Intake REstriction for Health OUtcome Support and Education (FIREHOUSE), a randomized controlled clinical trial (RCT). Male firefighters with WTC-LI and a BMI > 27 kg/m2 will be included. We will randomize subjects (1:1) to either: (1) Low Calorie Mediterranean (LoCalMed)—an integrative multifactorial, technology-supported approach focused on behavioral modification, nutritional education that will include a self-monitored diet with feedback, physical activity recommendations, and social cognitive theory-based group counseling sessions; or (2) Usual Care. Outcomes include reduction in body mass index (BMI) (primary), improvement in FEV1, fractional exhaled nitric oxide, pulse wave velocity, lipid profiles, targeted metabolic/clinical biomarkers, and quality of life measures (secondary). By implementing a technology-supported LoCalMed diet our FIREHOUSE RCT may help further the treatment of WTC associated pulmonary disease. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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16 pages, 336 KiB  
Article
Mortality among Fire Department of the City of New York Rescue and Recovery Workers Exposed to the World Trade Center Disaster, 2001–2017
by Hilary L. Colbeth, Rachel Zeig-Owens, Charles B. Hall, Mayris P. Webber, Theresa M. Schwartz and David J. Prezant
Int. J. Environ. Res. Public Health 2020, 17(17), 6266; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17176266 - 28 Aug 2020
Cited by 11 | Viewed by 2064 | Correction
Abstract
The World Trade Center (WTC) attacks on 9/11/2001 have consistently been associated with elevated rates of physical and mental health morbidities, while evidence about mortality has been limited. We examined mortality between 9/12/2001 and 12/31/2017 among 15,431 WTC-exposed Fire Department of the City [...] Read more.
The World Trade Center (WTC) attacks on 9/11/2001 have consistently been associated with elevated rates of physical and mental health morbidities, while evidence about mortality has been limited. We examined mortality between 9/12/2001 and 12/31/2017 among 15,431 WTC-exposed Fire Department of the City of New York (FDNY) firefighters and emergency medical service providers (EMS), specifically assessing associations between intensity of WTC-exposure and mortality risk. Standardized mortality ratios (SMR) and 95% confidence intervals (CI) compared FDNY cohort mortality with the US general population using life table analysis. Deaths were identified via linkage to the National Death Index. Cox proportional hazards regression models were used to identify associations between intensity of WTC-exposure and mortality, accounting for age, sex, race/ethnicity, smoking history, and other relevant confounders. We identified 546 deaths and a lower than expected all-cause mortality rate (SMR = 0.34; 95% CI, 0.31–0.37). No cause-specific SMRs were meaningfully elevated. Mortality hazard ratios showed no association or linear trend with level of WTC-exposure. Our results provide evidence of the healthy worker effect, despite exposure to the World Trade Center. More follow-up time may be needed to assess the full impact of WTC-exposure on mortality in this occupational population. Full article
(This article belongs to the Special Issue 9/11 Health Update)
13 pages, 635 KiB  
Article
PTSD and Depressive Symptoms as Potential Mediators of the Association between World Trade Center Exposure and Subjective Cognitive Concerns in Rescue/Recovery Workers
by Ankura Singh, Rachel Zeig-Owens, Laura Rabin, Theresa Schwartz, Mayris P. Webber, David Appel, David J. Prezant and Charles B. Hall
Int. J. Environ. Res. Public Health 2020, 17(16), 5683; https://doi.org/10.3390/ijerph17165683 - 06 Aug 2020
Cited by 13 | Viewed by 3006
Abstract
We observed that World Trade Center (WTC) exposure, post-traumatic stress disorder (PTSD) symptoms and depressive symptoms were associated with subjective cognitive concerns in Fire Department of the City of New York (FDNY) rescue/recovery workers. This follow-up study examined whether PTSD symptoms and/or depressive [...] Read more.
We observed that World Trade Center (WTC) exposure, post-traumatic stress disorder (PTSD) symptoms and depressive symptoms were associated with subjective cognitive concerns in Fire Department of the City of New York (FDNY) rescue/recovery workers. This follow-up study examined whether PTSD symptoms and/or depressive symptoms mediate the observed association between WTC exposure and subjective cognitive concerns. We included WTC-exposed FDNY workers who completed the Cognitive Function Instrument (CFI), measuring self-perceived cognitive decline (N = 9516). PTSD symptoms and depressive symptoms were assessed using the PCL-S and CES-D, respectively. Multivariable linear regression estimated the association between WTC exposure and CFI score, adjusting for confounders. Mediation analyses followed the methods of Vanderweele (2014). Participants’ average age at CFI assessment was 56.6 ± 7.6 years. Higher-intensity WTC exposure was associated with worse CFI score, an effect that was entirely mediated by PTSD symptoms (%mediated: 110.9%; 95%CI: 83.1–138.9). When substituting depressive symptoms for PTSD symptoms, the WTC exposure–CFI association was largely mediated (%mediated: 82.1%; 95%CI: 60.6–103.7). Our findings that PTSD symptoms and depressive symptoms mediate the association between WTC exposure and subjective cognitive concerns indicate that in the absence of these symptoms, WTC exposure in rescue/recovery workers would not be associated with subjective cognition. Interventions targeting PTSD and depression may have additional value in mitigating cognitive decline in WTC-exposed populations. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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13 pages, 798 KiB  
Article
The Intentional Self-Medication of 9/11-Related PTSD Symptoms with Alcohol: 15 Years after the Disaster
by Sascha K. Garrey, Alice E. Welch, Melanie H. Jacobson, Robert M. Brackbill and Lisa M. Gargano
Int. J. Environ. Res. Public Health 2020, 17(15), 5327; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17155327 - 24 Jul 2020
Cited by 11 | Viewed by 2886
Abstract
The self-medication hypothesis may explain the co-morbidity of affective and substance use disorders. Research shows increased prevalence, frequency, and intensity of binge drinking and post-traumatic stress disorder (PTSD) among those directly exposed to the 9/11 terrorist attacks on the World Trade Center (WTC), [...] Read more.
The self-medication hypothesis may explain the co-morbidity of affective and substance use disorders. Research shows increased prevalence, frequency, and intensity of binge drinking and post-traumatic stress disorder (PTSD) among those directly exposed to the 9/11 terrorist attacks on the World Trade Center (WTC), however, little is known about PTSD symptomology and intentional self-medication with alcohol (ISMA) among this group. We used WTC Health Registry data (N = 28,935) to describe the relationship between ISMA and specific symptom clusters of probable 9/11-related PTSD, the number of PTSD symptom clusters endorsed, and binge drinking intensity. Multivariable logistic regression models were used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CI). ISMA was most strongly associated with the hyperarousal PTSD symptom cluster (AOR = 2.04 [1.88, 2.21]) and the endorsement of one (AOR = 1.80 CI [1.65, 1.95]), two (AOR = 2.51 CI [2.28, 2.77]), or three (AOR = 2.84 CI [2.55, 3.17]) PTSD symptom clusters, indicating a clear dose–response relationship. A significant number of 9/11-exposed persons continue to experience PTSD symptoms and engage in ISMA as a potential coping mechanism. Repeated screenings for self-medicative alcohol use among survivors of mass traumas with PTSD symptoms is of public health importance. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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12 pages, 558 KiB  
Article
Injury Severity and Psychological Distress Sustained in the Aftermath of the Attacks of 11 September 2001 Predict Somatic Symptoms in World Trade Center Health Registry Enrollees Sixteen Years Later
by Howard E. Alper, Lisa M. Gargano, James E. Cone and Robert M. Brackbill
Int. J. Environ. Res. Public Health 2020, 17(12), 4232; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17124232 - 13 Jun 2020
Cited by 4 | Viewed by 2100
Abstract
The World Trade Center attacks of 11 September 2001 (9/11) have been associated with the subsequent development of chronic diseases. Few studies have investigated the burden of somatic symptoms on attack victims, or the association of such symptoms with exposure to the 9/11 [...] Read more.
The World Trade Center attacks of 11 September 2001 (9/11) have been associated with the subsequent development of chronic diseases. Few studies have investigated the burden of somatic symptoms on attack victims, or the association of such symptoms with exposure to the 9/11 attacks. World Trade Center Health Registry (Registry) enrollees who were present south of Chambers Street during or immediately after the 9/11 attacks and who provided consistent answers regarding injury sustained on 9/11 were followed prospectively for up to 16 years post-9/11/01. We employed linear regression to evaluate the associations between injury severity, psychological distress and somatic symptoms in 2322 persons who completed all four Registry surveys and a subsequent Health and Quality of Life survey. Twenty-one percent of subjects had a “very high” burden of somatic symptoms, greater than in populations not exposed to a disaster. Somatic symptoms exhibited a dose-response association separately with injury severity and psychological distress trajectories. Victims of the 9/11 attacks suffer from a substantial burden of somatic symptoms which are associated with physical and psychological consequences of exposure to the attacks. Physical and mental health professionals need to work together when treating those exposed to complex disasters such as 9/11. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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Review

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24 pages, 469 KiB  
Review
A Workshop on Cognitive Aging and Impairment in the 9/11-Exposed Population
by Robert D. Daniels, Sean A. P. Clouston, Charles B. Hall, Kristi R. Anderson, David A. Bennett, Evelyn J. Bromet, Geoffrey M. Calvert, Tania Carreón, Steven T. DeKosky, Erica D. Diminich, Caleb E. Finch, Sam Gandy, William C. Kreisl, Minos Kritikos, Travis L. Kubale, Michelle M. Mielke, Elaine R. Peskind, Murray A. Raskind, Marcus Richards, Mary Sano, Albeliz Santiago-Colón, Richard P. Sloan, Avron Spiro III, Neil Vasdev, Benjamin J. Luft and Dori B. Reissmanadd Show full author list remove Hide full author list
Int. J. Environ. Res. Public Health 2021, 18(2), 681; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18020681 - 14 Jan 2021
Cited by 11 | Viewed by 4756
Abstract
The terrorist attacks on 11 September 2001 potentially exposed more than 400,000 responders, workers, and residents to psychological and physical stressors, and numerous hazardous pollutants. In 2011, the World Trade Center Health Program (WTCHP) was mandated to monitor and treat persons with 9/11-related [...] Read more.
The terrorist attacks on 11 September 2001 potentially exposed more than 400,000 responders, workers, and residents to psychological and physical stressors, and numerous hazardous pollutants. In 2011, the World Trade Center Health Program (WTCHP) was mandated to monitor and treat persons with 9/11-related adverse health conditions and conduct research on physical and mental health conditions related to the attacks. Emerging evidence suggests that persons exposed to 9/11 may be at increased risk of developing mild cognitive impairment. To investigate further, the WTCHP convened a scientific workshop that examined the natural history of cognitive aging and impairment, biomarkers in the pathway of neurodegenerative diseases, the neuropathological changes associated with hazardous exposures, and the evidence of cognitive decline and impairment in the 9/11-exposed population. Invited participants included scientists actively involved in health-effects research of 9/11-exposed persons and other at-risk populations. Attendees shared relevant research results from their respective programs and discussed several options for enhancements to research and surveillance activities, including the development of a multi-institutional collaborative research network. The goal of this report is to outline the meeting’s agenda and provide an overview of the presentation materials and group discussion. Full article
(This article belongs to the Special Issue 9/11 Health Update)
25 pages, 756 KiB  
Review
World Trade Center Health Program: First Decade of Research
by Albeliz Santiago-Colón, Robert Daniels, Dori Reissman, Kristi Anderson, Geoffrey Calvert, Alexis Caplan, Tania Carreón, Alan Katruska, Travis Kubale, Ruiling Liu, Rhonda Nembhard, W. Allen Robison, James Yiin and John Howard
Int. J. Environ. Res. Public Health 2020, 17(19), 7290; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17197290 - 06 Oct 2020
Cited by 21 | Viewed by 5526
Abstract
The terrorist attacks on 11 September 2001 placed nearly a half million people at increased risk of adverse health. Health effects research began shortly after and continues today, now mostly as a coordinated effort under the federally mandated World Trade Center (WTC) Health [...] Read more.
The terrorist attacks on 11 September 2001 placed nearly a half million people at increased risk of adverse health. Health effects research began shortly after and continues today, now mostly as a coordinated effort under the federally mandated World Trade Center (WTC) Health Program (WTCHP). Established in 2011, the WTCHP provides medical monitoring and treatment of covered health conditions for responders and survivors and maintains a research program aimed to improve the care and well-being of the affected population. By 2020, funds in excess of USD 127 M had been awarded for health effects research. This review describes research findings and provides an overview of the WTCHP and its future directions. The literature was systematically searched for relevant articles published from 11 September 2001 through 30 June 2020. Synthesis was limited to broad categories of mental health, cancer, respiratory disease, vulnerable populations, and emerging conditions. In total, 944 WTC articles were published, including peer-reviewed articles funded by the WTCHP (n = 291) and other sources. Research has focused on characterizing the burden and etiology of WTC-related health conditions. As the program moves forward, translational research that directly enhances the care of individuals with chronic mental and physical health conditions is needed. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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16 pages, 1033 KiB  
Review
An Introduction to Probabilistic Record Linkage with a Focus on Linkage Processing for WTC Registries
by Jana Asher, Dean Resnick, Jennifer Brite, Robert Brackbill and James Cone
Int. J. Environ. Res. Public Health 2020, 17(18), 6937; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17186937 - 22 Sep 2020
Cited by 19 | Viewed by 4769
Abstract
Since its post-World War II inception, the science of record linkage has grown exponentially and is used across industrial, governmental, and academic agencies. The academic fields that rely on record linkage are diverse, ranging from history to public health to demography. In this [...] Read more.
Since its post-World War II inception, the science of record linkage has grown exponentially and is used across industrial, governmental, and academic agencies. The academic fields that rely on record linkage are diverse, ranging from history to public health to demography. In this paper, we introduce the different types of data linkage and give a historical context to their development. We then introduce the three types of underlying models for probabilistic record linkage: Fellegi-Sunter-based methods, machine learning methods, and Bayesian methods. Practical considerations, such as data standardization and privacy concerns, are then discussed. Finally, recommendations are given for organizations developing or maintaining record linkage programs, with an emphasis on organizations measuring long-term complications of disasters, such as 9/11. Full article
(This article belongs to the Special Issue 9/11 Health Update)
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7 pages, 288 KiB  
Correction
Correction: Colbeth et al. Mortality among Fire Department of the City of New York Rescue and Recovery Workers Exposed to the World Trade Center Disaster, 2001–2017. Int. J. Environ. Res. Public Health 2020, 17, 6266
by Hilary L. Colbeth, Rachel Zeig-Owens, Charles B. Hall, Mayris P. Webber, Theresa M. Schwartz and David J. Prezant
Int. J. Environ. Res. Public Health 2023, 20(16), 6585; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph20166585 - 16 Aug 2023
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Abstract
The original publication [...] Full article
(This article belongs to the Special Issue 9/11 Health Update)
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