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Full text of "WTC Environmental Health Center"

The WTC Environmental Health Program 

"Survivor program" 



Joan Reibman, MD 

Associate Professor of Medicine and Environmental 

Medicine 

New York University School of Medicine 

Bellevue Hospital 

November 2011 



WTC 
Environmental 

Health 
i Center ,' 



Bellevue Hospital Center 
Elmhurst Hospital Center 
Gouverneur Healthcare Services 




NEW YORK CITY 
HEALTH AND 
HOSPITALS 
CORPORATION 



nyc.gov/hhc 



WTC destruction as an environmental disaster 




Community at risk for WTC dust/fume exposure 



•60,000 residents south of Canal Street alone 

•300,000 area workers/office workers, commuters, teachers 

15,000 students 












Disaster exposure science and a community at risk 
Background history of the WTC EHC program 
Clinical findings of WTC EHC program 
Unanswered questions 



Environmental human exposure science 



Basic tenets of human exposure science: 

• Does an exposure factor have a potential health risk 
(biologic plausibility) 

• Exposure assessment 

• Human disease assessment 

• Estimate dose-response relationships 



Environmental disaster exposure science 



Systems in disarray 

Politics and economics complicate questions of potential health 
risk 

Exposure assessment may not be feasible 

Disease assessment systems not available 



Did WTC dust/fume exposure pose a health risk 

to the community 



Risk denied by EPA 

Residents told to damp mop 

Local workers returned to work 7 days after event 

Concept of potential health risk to surrounding community only 
accepted after delay 



Exposure assessment - toxic agents? 




1.2 million tons of 
building materials 

90% of settled particles 
>10 Dm diameter 

1 1 ,000 tons of particles < 
2.5 Dm diameter 



"Lioy et al. Environmental Health Perspectives Vol 110,, July 2002 



Characteristics of settled WTC dust 



Alkaline (pH9-11) 

Construction materials 
Cement 
Concrete 
Wallboard 



Particulate matter 
Calcium sulfate (gypsum) 
Calcium carbonate 
Crystalline silica 

Fibers 

Fibrous glass 
Gypsum fibers 
Chrysotile asbestos 



Banauch et al. Curr. Opinion Pulm Med 2005, 1 1 :1 60-1 68 asbestos 
USGS Environmental Studies of WTC 




concrete 



glass fiber 



Chemical constituents of WTC dusts 



Combustion of jet fuel 

Combustion products of 
plastics, metals, woods, 
insulation, fluorescent lights, 
computer and video monitors 



Organic pollutants 
Polycyclic aromatic hydrocarbons 

Hydrocarbons 
Napthalene 

Polychlorinated biphenyls (PCBs) 
Dioxins 
Benzene 



Heavy metals 
Mercury 
Lead 



Banauch et al. Curr. Opinion Pulm Med 2005, 1 1 :1 60-1 68 



Exposure assessment for community members 



Complicated by variety of exposure possibilities 

Variable amount of time in area (there on 9/1 1 , evacuated or 
not, returned episodically to clean) 

No studies done immediately after event to assess exposure 

Recall 



Acute exposures - Dust cloud(s) 




r ^"S*~ 



Debris before buildings collapsed 

Multiple dust clouds 

Extensive dust in afternoon after buildings collapsed 



Chronic exposures - Outdoor dust exposures 

Area workers returned to work on September 1 7, 2001 





Chronic exposures - Indoor dust exposures 




Dust settled inside 
buildings/ventilation systems 

Dust resuspended from 
incompletely cleaned 
ventilation systems 




Indoor dust exposures 




Few residents evacuated 



Chemical composition 
similar to outdoor 




Gases and fumes 

• Fires burned through 
December 2001 



Structure of composite exposure scales generated by 

principal components analysis of DOHMH WTC 
Regis try study 



Acute 



Component Variables 



Personal appearance after thickest part of cloud 

Visibility in thickest part of cloud 

Time first caught, relative to WTC collapses 



Duration of time in dust cloud 
Prop.of time in thickest part of cloud 



Composite scale 



Dust cloud - Density 



Dust cloud-Time 



Chronic 



Extent of dust coverage at home or workplace 
Depth of thickest dust layer at home or workplace 
Proportion of home or workplace most affected 



Smelled smoke inside, outside, both 
Duration of time during which smelled smoke 



Time at home or workplace 

Month first at home or workplace after 9/11 



Participated in cleaning of home or workplace 

Number of items cleaned by subject* 

Time spent cleaning home or workplace 



Dust - Home/Workplace 



Smoke - 
Home/Workplace 



Time - Home/Workplace 



Involvement in cleaning 
Home/Workplace 



Maslow etal. Chronic and acute exposures to the WTC disaster and lower respiratory symptoms" 
area residents and workers, Am J Pub Health in press 2011 



Disease assessment in the community 



• October 1 1 , 2001 - Pace University Community Forum 

• Academic-community coalitions 

• FDNY 

• Organized labor/Occupational clinics/local politicians 

• WTC Workers Medical Screening/Monitoring/Treatment 
program 

• Community 



WTC Residents Respiratory Health Study 




LEGEM 

.1 Federal anddi 

1 Pr-crrincnl Ri;-i|i 

) Points of IrriMV 

] Parks ar«J P(«a • 

1 MainSti«tS 

3 Landmarks 
-»- Subway Line £f 
m Rouls Marking: 
• Express 
B Local 



Collaborative effort of NYU, New 
York State Department of Health 
and local community 

Funded by CDC and NIH(NIEHS) 

Cross-sectional study of control 
and exposed population 
designed, implemented and 
completed 16 months after 
9/11/01 



Responses analyzed from 2,812 
individuals 



Persistent 13 new-onset respiratory symptoms in 
"previously normal" residents 







E> 

(n= 


(posed 
=2410) 


Control 
(n=271) 


Crude Incidence ratio 
(95% CI)* 


Cough without cold,% 




16.0 


4.0 


3.99(2.15-7.38)* 


Daytime SOB, % 




10.6 


3.6 


2.94(1.53-5.66)* 


Wheeze, % 




10.5 


1.6 


6.50(2.44-17.33)* 


AM chest tightness, % 




8.4 


1.6 


5.21 (1.95-13.91)* 


SOB after exercise, % 




7.4 


1.7 


4.45(1.66-11.91)* 


Night-time SOB, % 




6.2 


0.8 


7.64(1.90-30.70)* 


Any of the above symptoms, % 




26.4 


7.5 


3.53 (2.28-5.47)* 



^Symptom frequency > 2 days per week in the past 4 weeks. 

* Effect still statistically significant after adjusting for age, gender, education, smoking and race. 

Reibman etal., Environ Health Perspectives 113: 406;2005 



Increase in medical consultation and asthma 
medicine use in previously normal residents 3 







Exposed 
(n=2410) 


Control 
(n=271) 


Crude IR 
(95% CI)* 


Unplanned Medical Visits 
(in the past 12 months) 


13.7% 


7.8% 


1.77(1.16-2.70)* 


Fast Relief Med Use 
(in the past 4 weeks) 


8.0% 


3.3% 


2.41 (1.25-4.65)* 


Controller Med Use 
(in the past 4 weeks) 


8.6% 


3.7% 


2.33(1.25-4.34)* 



a No diagnosis of asthma, chronic obstructive pulmonary disease, chronic bronchitis, or other lung disease 

before 9/1 1/2001. 

* Effect still statistically significant after adjusting for age, gender, education, and race. 

Lin S. et al., Amer J Epidemiol 1 62:499;2005 



New onset symptoms associated with 
persistence of dust or odors in home 



2.50 




New upper f 



New lower t 



New persistent New persistent 
upper t lower t 



■ < 1 month (ref.) 

■ 1 - 3 months 

□ 3 - 6 months 

□ > 6 months 



Lin et al. J. Asthma 2007 



NYC DOHMH WTC Health Registry 



Studies increased respiratory symptoms in subsequent DOHMH 
WTC Registry studies in individuals surveyed between 2003 - 
2004 



WTC Environmental Health Center 



Bellevue Hospital/NYU LMC 

• 2002 community collaborative pilot program for treatment of 
residents/area workers in the Bellevue Hospital Asthma 
clinic 

WTC Environmental Health Center 

• 2005 American Red Cross Liberty Disaster Relief Fund 

• 2006 funding from City of New York 

• 2008 first Federal funding (CDC-NIOSH) 



WTC Environmental Health Center 



Treatment program for individuals with presumed WTC-related illness 

• Had to have potential exposure (geographic boundaries) 

• Had to have symptom (initially physical, subsequently mental 
health or physical) 

Target populations: Non-rescue workers 

• residents 

• local workers 

• students 

• clean-up workers 

Multidisciplinary treatment program (medical, mental health, social 
services) 

Nearly 6,000 individuals enrolled between September 2005 to 
September 201 1 for treatment 



Characteristics of WTC EHC population 
enrolled 9/2005 - 5/2008 (N = 1898) 



Characteristic 


Total 


Gender, N (%) 
Male 
Female 


1005(53) 
893 (47) 


Age, mean+SD 


48 + 12 


Race, N (%) 
White 
Black 
Asian 


867 (46) 
318(17) 
217(11) 


Ethnicity, N (%) 
Hispanic 


792 (42) 


Dust cloud 


740 (40) 



Disease assessment - disease characteristics 

(symptoms) 

New onset persistent symptoms in previously normal 

WTC EHC populations 

(N = 1898) 




1 Total 

1 Local worker 
I Resident 
1 Clean-up 
1 Rescue 



Cough 



Wheeze 



DOE 



Chest tightness 



Sinus/nasal 



Reibman etal. Characteristics of a residential and working community with diverse exposure 
to WTC dust, gas and fumes J Occup Env Med 2009 



CASE MR 



37 year old resident of Lower Manhattan (Beekman Street) 

Previously healthy (training for marathon), no history of childhood 
asthma/lifelong nonsmoker 

Not in dust cloud 

Stayed in apartment and cleaned dust-covered apartment 

Onset of shortness of breath and wheezing 6 months later 

Presented to WTC EHC in 2006 with persistent upper airway symptoms 
(nasal congestion, post nasal drip) and daily lower airway symptoms 
(shortness of breath, wheezing) 

Treated aggressively for asthma 

Continues to need therapy to control symptoms 



Flow use. 




Patterns of spirometry in WTC EHC patients 

with < 5 p-y tobacco use 
(N = 1109) 



Spirometry pattern 


Total 
N=1109 


Normal 


790(71) 


Obstructed 1 , N (%) 


67(6) 


Low FVC 2 , N (%) 


224 (20) 


Obstructed 

and low FVC 3 , N (%) 


28(3) 



How can we explain respiratory symptoms in population with normal 
lung function 

• Hyperresponsiveness? 

• Spirometry unable to detect small airway damage? 
•Other reasons - cardiac, mental health? 



Disease assessment - disease marker 
Spirometry in firefighters before and after 9/1 1 

6-month exam 
% predicted (L) 

FVC 90 (4.63) 

FEV! 90 (3.88) 

FEV/FVC 0.78 



Banauch et al Am J Resp Crit Care Med 2003: 1 68:54-62 



Spirometry in firefighters before and after 9/1 1 

Pre-WTC 1 -month exam 6-month exam 

% predicted (L) % predicted (L) % predicted (L) 



FVC 


99 (4.94) 


94 (4.70) 


90 (4.63) 


FEV 1 


103(4.22) 


96 (3.97) 


90 (3.88) 


FEV/FVC 


0.86 


0.79 


0.78 



6 year assessment: FDNY lost 360 - 390 ml/year of FEN^ 
(normal loss of 31 ml each year) 

World Trade Center Health Impacts on FDNY Rescue Workers: A 6 Year Assessment 9/01 
9/07 Fire Department, City of NY 2007 



Impulse oscillometry as a non-invasive way to 
assess lung function, including distal airways 



IOS measuares pressure waves applied externally to respiratory symptom at 
different oscillating frequencies 

Small studies of WTC patients suggested abnormalities in IOS (Oppenheimer et al. 
Chest 2007) 

Case-control study of DOHMH WTC Registry area residents and workers - elevated 
IOS measurements(R5, R5-20) associated with symptoms even in those with normal 
spirometry 



q 



p < 0.0001 



p = 0.014 



p < 0.0001 



n=40 n=25 
BMI < 25 



y 



n=51 n=130 
BMI 25 - 29 



n=69 n=59 
BMI >= 30 



Friedman et al. Case-control study of lung function in World Trade Center Health Registry area 
residents and workers Amer J Resp Crit Care Med 2011 



IOS (R5-20) was increased in WTC EHC 
patients compared to in asymptomatic control 
group 



E — 
o w 



o ^ 



DC 



AS group LRS LRS LRS Low FVC and 

All spirometry Normal Obstructed Low FVC obstructed 
patterns spirometry pattern pattern pattern 



IOS increased with severity of symptom (wheeze) 



Turetz et al. manuscript submitted 



Pathologic findings in WTC EHC patients 

Case series of patients (N = 12) who underwent VATS (video 
assisted thoracoscopic surgery) for clinical indications 

Pathologic findings 

• patchy interstitial fibrosis 

• bronchiolitis and small airways abnormalities 

• emphysematous changes in all 

• intracellular birefringent particles under polarizing light 
microscopy 



Caplan-Shaw et al. JOEM 201 1 



Particle analysis of lung biopsy specimens 



Scanning electron microscopy with 
energy dispersive x-ray spectroscopy 
(SEM-EDS) performed on 5 samples 

Silica 

Aluminum silicate 

Titanium 

Talc 

Metals - steel, copper, chromium, 




Disease heterogeneity in response to 
environmental exposure 



Nasal/ Cough Irritant Airway damage 
sinus asthma (bronchiectasis) 



Sarcoid 



Interstitial lung 
disease (NSIP, 
IMP, HP, ?) 




Dose 



Individual susceptibility 
Atopy 
Tobacco 
Immune 



Lung function over time in community members 

enrolled in WTC EHC 
(linear annual change ml/year) 



FVC 


FEV, 




Estimate 
ml/year 


SE 




95% CI 


p-value 


Estimate 
ml/year 


SE 


95% CI 


p-value 


Total 


54 


7 


(41,67) 


<0.0001 


30 


5 


(19,40) 


<0.0001 


Spirometry pattern 










Normal 


43 


8 


(28,58) 


<0.0001 


15 


6 


(3,27) 


0.02 


Low FVC 


84 


13 


(58,110) 


<0.0001 


37 


9 


(18,56) 


0.0001 


Obstructed 


-47 


33 


(-115,20) 


0.163 


46 


22 


(2,91) 


0.04 


Low 

FVC/Obstru 

cted 


115 


38 


(37,193) 


0.005 


111 


36 


(39,183) 


0.003 



Linear mixed effects model adjusted for age, BMI, gender, race/ethnicity, dust-cloud 
exposure, smoking status, and WTC exposure category 
Liu et al. manuscript submitted 



CD 

-i— ■ 

o 

CD 
Q. 

cr- o 



Spirometry in patients in the WTC EHC improved, but 
did not return to normal if baseline pattern was 

abnormal 

(baseline (white) last visit (grey) 



FVC 



P=0.0005 



M 



□ baseline 

□ last visit 



■I ^=^ 



P=0.0007 



^B 






P=0.036 



CD 

-i— • 

O 

T3 

CD 

Q. 



Normal 



Low VC Obstructed Low VC/Obs 



FEV 1 



P=0.004 




e 






□ baseline 

□ last visit 



P<0.0001 






P=D35 



P=0.B03 



Normal 



Low VC Obstructed Low VC/Obs 



P-values calculated using Wilcoxon signed rank test for paired data 
Liu et al. manuscript submitted 



Lung function over time in community members 
enrolled in WTC EHC by target category 

(linear annual change ml/year) 





FVC 


FEV, 




Estimate 
ml/year 


SE 


95% CI 


p-value 


Estimate 
ml/year 


SE 


95% CI 


p-value 


Total 
population 


54 


7 


(41,67) 


<0.0001 


30 


5 


(19,40) 


<0.0001 


WTC exposure category 




Resident 


53 


18 


(18,88) 


0.003 


26 


13 


(0,51) 


0.05 


Local worker 


20 


11 


(-2,41) 


0.075 


7 


9 


(-10,24) 


0.40 


Resc/recov 


69 


10 


(50,88) 


<0.0001 


39 


8 


(22,55) 


<0.0001 


Clean-up 


114 


29 


(56,173) 


0.0002 


61 


18 


(26,96) 


0.001 



Linear mixed effects model adjusted for age, BMI, gender, race/ethnicity, dust-cloud 
exposure, smoking status 
Liu et al. manuscript submitted 



Risk for probable PTSD in Patients of the WTC EHC 
enrolled with physical symptoms 4-7 years after 9/1 1 

In = 1825^ 





N 


(%) 1 


% PTSD sx 


Adjusted OR 3 








within 


each 


(95% CI) 








category 




Age 












<25 


30 


(1.6) 




33.3 


1 


25-44 


612 


(33.5) 




41.5 


0.91 (0.26-3.19) 


45-64 


1023 


(56.1) 




45.0 


1.11 (0.32-3.85) 


65+ 


160 


(8.8) 




28.8 


0.68(0.18-2.52) 


Gender 












Male 


954 


(52.3) 




40.4 


1 


Female 


871 


(47.7) 




44.2 


1.37(1.00-1.87 


Race/Ethnicity 












NH White 


577 


(31.6) 




35.9 


1 


NH Black 


310 


(17.0) 




34.2 


0.6 (0.38-0.92) 


Hispanic 


725 


(39.7) 




51.3 


1.23(0.83-1.83) 


Asian 


174 


(9.5) 




37.9 


0.53(0.26-1.08) 


Income 












< 1 5K/year 


775 


(42.5) 




53.8 


2.97 (2.06-4.28) 


>15-30K/year 


327 


(17.9) 




43.4 


1.90(1.24-2.91) 


>30K/year 


684 


(37.5) 




28.4 


1 



Probable PTSD in Patients of the WTC EHC enrolled 
with physical symptoms 4-7 years after 9/1 1 (n = 1 825) 





N 


(%) 1 


% PTSD sx 

within each 

category 


Adjusted OR 3 
(95% CI) 


Exposure Category 










Local worker 


782 


(42.9) 


38.2 


1 


Clean-up worker 


440 


(24.1) 


54.8 


0.74(0.42-1.3) 


Resident 


364 


(20.0) 


37.6 


0.81 (0.53-1.23) 


Rescue/recovery 


184 


(10.1) 


41.3 


1 .45 (0.86-2.45) 


Other 


55 


(3.0) 


30.9 


0.71 (0.32-1.58) 


Dust cloud 










No 


981 


(54.7) 


38.1 


1 


Yes 


813 


(45.3) 


46.7 


2.12(1.54-2.93) 


Respiratory symptoms 










Upper and lower 


423 


(26.8) 


56.7 


2.81 (1.8-4.38) 


Lower only 


659 


(41.7) 


41.3 


1.45(0.96-2.19) 


Upper only 


155 


(7.7) 


38.8 


1.71 (0.94-3.1) 


Neither 


378 


(23.9) 


25.4 


1 


Dyspnea score 










>3 


245 


(20.5) 


58.8 


2.39(1.64-3.49) 


<3 


949 


(79.5) 


31.4 


1 


Spirometry category 










Normal 


1054 


(69.5) 


41.2 


1 


Abnormal 


462 


(30.5) 


42.6 


0.87(0.62-1.22) 



Manetti-cusa et al. manuscript in preparation 



Preliminary data on children < 18 on 9/1 1 
Demographic characteristics (n = 87*) 



Characteristic 


Sex, % 


Female 


55.0 


Male 


45.0 


Age on 9/11 (range) 


11 (0-18) 


Race/Ethnicity, % 


White 


53.2 


Black 


13.1 


Hispanic 


23.9 


Asian 


9.8 



Children included if < 1 8 on 9/1 1 (n = 1 56) and had 
complete data set (n = 87) 
Trasande and Fiorino et al. manuscript in preparation 



Exposure characteristics of children in the WTC 

EHC 






Exposure characteristics 


Caught in dust cloud, % 


38.5 


Heavy volume of dust in clothing, hair, % 


22.5 


Dust in home, % 


36.7 


Heavy dust in home, % 


18.6 


School in Southern Manhattan, % 


61.4 



Presence in dust cloud and risk for abnormal 

lung function in children 



New asthma diagnosis in 22.6%, mean latency of 
3.2 years 



OR 


P value 


FEV 1 < LLN 2.5 


ns 


FVC < LLN 3.9 


ns 


FEV/FVC < LLN 5.6 


0.02 


FEF 25-75 < LLN 3.3 


0.09 


Obstructive pattern 8.8 


0.009 



LLN = lower limit of normal 
Data adjusted for BMI category 



Unanswered questions in the "survivor" population 

Medical questions 

• Cancer risk 

• Lung disease - long term progression, types, how to treat 

• Connective tissue disorders 

• Neurologic sequela - headaches, neuropathy 

• Vulnerable populations 
Mental health 

• who is at risk for persistent PTSD 

• long term outcomes 

• treatment of PTSD in civilian populations and associated 
with complex mental health and physical co-morbid 
conditions and socioeconomic issues 

• risk for cognitive defects with intractable PTSD 



Unanswered questions in the "survivor" population 



Children 

• Medical 

• What are their lung risks 

• Are there developmental/endocrinologic risks 

• Mental health 



Acknowledgements 



Residents Study 

Linda Rogers, MD 

Shao Lin, PhD 

Marcy Lopez 

Syni-An Hwang, Ph.D. 
James Bower 
Mridu Gulati, M.D. 
Kenneth Berger, M.D. 
Anne Hoerning, MSW 
Marcy Lopez 
Heidi Lee 

Community 

organizations 

Beyond Ground Zero 

Network 

9/11 Environmental 

Action 

Battery Park Residents 

Coalition 

Independence Plaza 

Tenants Org 

Southbridge Tenants Org 



Biostatistics/Epi/Data 

Mengling Liu, PhD 

Yongzhao Shao, PhD 

Michael Marmor, PhD 

Qinyi Cheng, PhD 

Meng Qian 

Maria Elena 

Fernandez-Beros, 

PhD 

DOHMH 

Steven Friedman, MD 

Carey Maslow, PhD 

Bellevue Hospital 
HHC 

Alan Aviles 

Terry Miles 

Ruchel Ramos 



WTC Environmental Center 
Sam Parsia, MD 
Caralee Caplan Shaw, MD 
Roberta Goldring, MD 
Ken Berger, MD 
JudySu, MD 
Sonia Cabrera, MD 
Angeliki Kazeros, MD 
Meredith Turetz, MD 
Leonardo Trasande, MD 
Elizabeth Fiorino, MD 
Waiwah Chung, RN 
MarkWilkenfeldMD 



Nomi Levy-Carrick, MD 
Julian Manetti-Cusa, PhD 
Alicia Munoz 
Lucia Ferri, PhD 
Nerina Garcia, PhD 
Candela Bonaccorso, PhD 



Herman Yee, MD 



Early onset disease: Acute eosinophilic 
pneumonia in a firefighter 




Rom et al. Am J Respir Crit Care Med 2002 



Mineralogic analysis of bronchoalveolar lavage 

from firefighter 





D 


^ 


Mr uu j| v 




5,' ' ^^BUB^^ 


■BSH 
1 


^M 3h*ti 



(4) Amosite asbestos fiber (uncoated) (B) Fly ash particle 



(C) Degraded fibrous glass. 



Rom et al. Am J Respir Crit Care Med 2002