WTC FDNY CLinical Center

World Trade Center Health Studies

David Prezant, MD

Chief Medical Officer, Office of Medical Affairs, FDNY

PI, FDNY-WTC NIOSH Funded Data Center

Co-Director FDNY-WTC Monitoring & Treatment Programs

Professor of Medicine, AECOM

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September 11, 2001

The terrorist attack on the World
Trade Center and its consequent
collapses killed 2,800 persons,
including 343 FDNY rescue/recovery
workers.

Overall, ~ 16,000 FDNY rescue
workers participated in the intense
rescue/recovery effort, which
started immediately and continued
for more than 10 months.

1,600 FDNY firefighters and EMS
workers were present when the
buildings came down and 6,600
were there by the end of day 1.

CDUST

• Small & Large particles

• Alkaline pH (ex. Lye)

• Larger the size, the more alkaline the pH

• Large Particles reached lower airways

- High concentrations

- Mouth breathing W*

ze (MMAD urn)

.5 10

Chen et al; Lancet 2002;360:S37-8
Gavett et al; Environ Health Pers

Perspect 2003;111:981-91

Review of WTC Exposures

\y

The exposure mix (partial list):

• Pulverized cement, gypsum

• Pulverized glass

• Asbestos

• Silica

• Fibrous glass

• Heavy metals

• Volatile organic compounds

• Organic products of the combustion
of bldg components & jet fuel

- PAHs, dioxins, PCBs, etc

■ *%>

st, surgicaLor N95
the type of respiratory
first responders shou
FIRE orHAZMATever

V

tor but

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difficult to wear

FDNY Firefighter with Pneumonitis

Bronchoscopic Lavage - 3 weeks later

Uncoated asbestos fiber Degraded fibrous glass

Fly ash particle

Rom, Weiden, Prezant, et al. Am J Resp Crit Care Med 2002, 166; 797

FDNY Firefighter
Dust-Induced Inflammation

Induced Sputum - 10 months later

Particle Size Distributions Induced Sputum
& Settled WTC Aerosol

NY

Fire fighters - - - Q Dust

Xgl

2 15
10

a 5

0m

o.i

i

10

100

Particle Diameter (microns)

1000

Fireman, Kelly, Prezant, etal. Environmental Health Perspectives; 2004

FDNY WTC Monitoring & Treatment Program

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Exposures

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FDNY-WTC
ARRIVAL GRPS

• ~ 15,700 AT WTC SITE:

• Initial Arrival:

• Day 1- AM of 9/11/01

• 14% of workforce

• Day 1-PM of 9/11/01 &
Day 2 -9/12/02

• 60% of workforce

• Day 3-14

• 15% of workforce

• After Day 14

• 10% of workforce

> •

■

H

X

FDNY WTC MONITORING EXAM: Patient Flow

Monitoring
Sign In

Medical
Questionnaire

Vitals

PFT

EKG

Hearing

Chest Xray
Every 2 yrs

Immunizations

Stair Master
(Active Only)

Vision
(Active only)

Physician

Wellness Check or Mental Health Structured
Interview (DIS) by MSW or RN

Self-Administered
Mental Health
Questionnaire

Mental

Health

Treatment

Referral

Treatment / Referral Options if Needed

Sign Out &
Reschedule Annually

Physical

Health

Diagnosis &

Treatment

Referrals

Medications

Benefits
Counseling

FDNY-WTC Monitoring & Treatment Program
Delivered Through a Health Benefits Program Model

FDNY - WTC Health Monitoring and Treatment Program

Data Center

for

Coordination

Analysis

&
Reporting

Claims
Processing

Patient Care
Coordination & Services

Clinical Center
for
Physical & Mental Health

Monitoring

Diagnostic Testing
& Treatment

Pharmacy
Benefits

Clinical <-> Data Integration

Patient
Micro Level

Eligibility determination

Monitoring

Treatment

Pre. vs Post WTC Data

Diagnostic Testing

Prescription Meds.

Medical Records

Clinician-Patient Relationship

Cohort
Macro Level

Diagnostic Definitions
Monitoring Protocols
Treatment Protocols
Pre. vs Post WTC Data
Disease Surveillance
Outcomes

Programmatic Relationships

- Patient Groups

- Medical Community

- Government

FDNYWTC MEDICAL
MONITORING

• Oct. 2001 to Mar. 2002:

10,000 Visit 1 Baseline Medicals

- Firefighters, EMS, Officers

• Totals through 7/31/11:

- 15,375 Baseline Medicals

• (98% compliance)

- Visit 4 Medicals started 2008

- Already 82% of cohort examined

- Visit 5 Medicals

- Already 70% of cohort examined

The New England Journal of Medicine

Sept 2002

COUGH AND BRONCHIAL RESPONSIVENESS IN FIREFIGHTERS

AT THE WORLD TRADE CENTER SITE

David J. Prezant, M.D., Michael Wei den, M.D., Gisela L Banauch, M.D., Georgeann McGuinness, M.D.,
William N. Rom, M.D., M.P.H., Thomas K. Aldrich, M.D., and Kerry J. Kelly, M.D.

Abstract

Background Workers from the Fire Department of
New York City were exposed to a variety of inhaled
materials during and after the collapse of the World
Trade Center. We evaluated clinical features in a series
of 332 firefighters in whom severe cough developed
after exposure and the prevalence and severity of
bronchial hyperreactivity in firefighters without severe
cough classified according to the level of exposure.

Methods "World Trade Center cough" was defined
as a persistent cough that developed after exposure to
the site and was accompanied by respiratory symi

THE September 11, 2001,, terrorist attack that
resulted in the collapse of New York City^s
World Trade Center led to an intense, short-
term exposure to inorganic dust, products
of pyrolysis, and other respirable materials. The Fire
Department of New York City (FDNY) operated a
continuous rescue and recovery effort at the site in-
volving approximately 11,000 firefighters, who were
exposed to such respiratory irritants, 1 which have
been implicated in the development of airflow ob-
struction. 2 3 We identified conditions associated with

Respiratory Symptom Time Trends:
Cross-sectional analysis (N= 11,315)

2001-2009

-♦— Cough
-■— Dyspnea
-a— Wheeze
-*— Sinus
-*— sthroat
■+— GERD

t 1 1 1 1 1 r

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8

» Not shown :
Significant
Exposure
Response Effect:

Arrival Time

Duration

1. Webber, Niles, Kelly Prezant et al; Environ Health Perspectives 2009

2. Weakley, Webber, Kelly, Prezant, et al Preventive Medicine 9/2011

The NEW ENGLAND
JOURNAL of MEDICINE

rp.Txm.rsLPrPD en imi2

APRIL 3, 2010

VDL =.-M NO. 1-4

Lung Function in Rescue Workers
at the World Trade Center after 7 Years

Thomas K.Aldrich. M .D.. Jackson Gu stave. M.P.H..ChaHes B. Hall. Ph.D.. Hil lei W.Cohen. Dr.P.H..

Maoris P.Webber. Dr.P.H.. Rachel Zeiff-Owens. M.P.H.. Kaitlyn Cosenza. B.A..Vasilio5Christodoulou. BA..

Lara Glass. M.P.H.. Fairc-uz Al-Qthman. M.D.. Michael D. Weiden. M.D.. Kerry J. Kelly. M.D..

and David J. Prezant. M.D.

akktb a-c:t

• OBJECTIVE: To assess the longer-term lung function trends in FDNY
workers exposed to WTC dust

- On average, did the initial decline in lung function

recover, persist, or worsen?

Characteristics of cohort - Post QA

FIRE

EMS

TOTAL

Number of Persons

10,870

1,911

12,781

Number of Spirometries

48,659

13,083

61 ,742

Length of Follow-up post-
9/11 (median)

6.1 years

6.4 years

6.2 years

2,099 were present during the morning of 9/11

RESULTS : Lung Function Decline Since 9/11 :
Nonsmokinq EMS Exposed to WTC Dust

Fire, Never Smokers (n=7,364)
predicted

EMS, Never Smokers (n=967)

predicted

-1.5

1.5 3 4.5

Years since 9/1 1/2001

Compared to firefighters:

Pre-9/11 , lung function was lower, reflecting the higher percentage of

women and less rigorous lung function requirements for EMS

After 9/11 , patterns of decline similar but drop in year 1, although substantial,
was less than Fire because EMS job-tasks resulted in lesser exposure

RESULTS : Lung Function Decline Since 9/11
Impact of Tobacco Smoke Significant but Small

4.5 -

^ 4.0 -

CD *3-*^
GO

"O
<

Fire, Never Smokers (n=7,364)
predicted

Fire, Post-9/1 1 ever Smokers (n=61 1 )

-1.5

o

1.5 3 4.5

Years since 9/1 1/2001

For both Fire & EMS (not shown), cigarette smokers had lower lung function
at all time points, but main impact was 9/11 exposure.

Another way to look at decline rates is to determine the percentage of the
group developing abnormal lung function.

Short-term effects

of WTC exposure:

The First Year

In our first study of lung function, over
12,000 FDNY rescue workers had
spirometry with measures of the FEV1
(Forced expiratory volume in first sec.)

FIRST YEAR POST-9/11:

Average decline in FEV1 = 372 ml

• Approx. 12 times the annual
age-related decline pre-9/11

Greater declines associated with
greater exposures:

• Fire > EMS

• Yet, EMS still substantial

Intermediate
Arrival Time Exposure

EMS Fire

Work Assignment Exposure

Banauch et al, AJRCCM 2006; 1 74: 31 2.

Firefighters battle

Trade Center cough''

WTC COUGH

Between 9/11/01 and 3/10/08:

• Syndrome of Asthma, Sinusitis & GERD

• 1,720 Presented for FDNY Pulmonary Evaluation

and had all Pulmonary Tests at Single Ctr.
• Obstructive vs. Restrictive Physiology ???

Source: Weiden, Ferrier, Nolan, Rom, Comfort, Gustave, Zeig-Owens, Zeng, Goldring,
Berger, Cosenza, Lee, Webber, Kelly, Aldrich & Prezant; CHEST. 2010: 137:1-9

*WTC Cough': Pulmonary Evaluation Cohort (N= 1,720)

A.

0.00 1

B

p < 0.0001

i r z =0i29

-50 50 100

Post BD FEV 1 % Change

LOO

8

H 0.75

0.50

0.00

p < 0.0001

l 2 = 0.14

" ■ ■ ^ *♦ * V

F

100 200 300

RV ^Predicted

All regressions adjusted for smoking, gender, height, weight, age & race

Source: Weiden, et al CHEST. 2010: 137:1-9

*WTC Cough': Pulmonary Evaluation Cohort (N= 1,720)

B

11

O o

LU +-

(N in Bin)

*WTC Cough': Pulmonary Evaluation Cohort (N= 1,720)

Bronchial Wall Thickening
On Inspiratory Imaging

Bronchial Wall Thickening
On Inspiratory Imaging

IF

l

Prezant, Banauch, Weiden, Kelly et al; NEJM 2002;347:806-15.

Air Trapping on Expiratory Imaging

*WTC Cough': Pulmonary Evaluation Cohort (N= 1,720)

C

CD

« O)

o

(0

(65) (114) (104) (48) (26) (25)

RV % Bin
(N in Bin)

"WTC Cough': Pulmonary Evaluation Cohort (N= 1,720)

FDNY Pulmonary Evaluation Cohort:
FEV1/FVC < 0-76 (LLN)
BD Response (>12%),
High RV (>120% predicted)
MC Reactivity (slope >0.13):
Low FEV1/FVC Ratio, BD Response, High RV OR Reactivity:

• 1,015/1,720 (59%)

Of the 1,720 only 30 (1.7%) with interstitial disease

• 27 with Post 9/11/01 Sarcoidosis (Volumes & DLCO <80% in 1)

• 3 with Interstitial Dx. on CT (Volumes & DLCO <80% in 2)

Symptoms without physiologic explanation but not restrictive

• 675/1,720 (39%)

Source: Weiden, et al CHEST. 2010: 137:1-9

INTERSTITIAL LUNG DISEASE IS RARE

World Trade Center
"Sarcoid-Like"
Granulomatous
Pulmonary Disease

WTC - Related Sarcoid Like Granulomatous
Pulmonary Disease in FDNY Rescue Workers

'Sarcoid-like" Granulomatous Pneumonitis
FDNY: Pre & Post WTC

•Pre-WTC = 13 / 100,000 in FDNY rescue workers
•Post-FDNY= 86/ 100,000 in first 12 months; 22/ 100,000 yrs 2-4

Izbicki, Banauch, Weiden, Kelly, Prezant CHEST May 2007

WTC-Related Sarcoid-Like Granulomatous Disease
in FDNY Rescue Workers - Clinical Course

• Pre-WTC : All with Thoracic Lymph Nodes

• 1 liver, 1 bone, 2 treated (? need)

» No Bronchodilator response, No Hyperreactivity

• Post-WTC : All with Thoracic Lymph Nodes

• 2 skin (EN), 2 Liver, 3 Bone, 1 Cardiac
» Obstructive Airways Disease = 38 to 65%
» Oral Corticosteroids = 8 (31 %)

» No transplants, no fatalities
» Hypersensitivity Pneumonitis unlikely
» 6 resolved spontaneously but all cases with
lymph nodes "1/3 with extrathoracic disease

Izbicki, Banauch, Weiden, Kelly, Prezant CHEST May 2007 29

Probable PTSD Time Trends:
Cross-sectional analysis 2001-2010

(N= 11,006)

Prevalence of Probable PTSD by WTC Arrival Group

Yearl

~i r

Year 2 Year 3 Year 4

■*— Arrival Group 1
-■ — Arrival Group 2
-*— Arrival Group 3
•— Arrival Group 4
Overall

Dotted lines show
extrapolations
across Year 5
(not measured).

Year 6 Year 7 Year 8 Year 9

Time Period

Soo, Webber, Kelly Prezant et al; Disaster Med & Preparedness, 2011

Between

01 and 9/10/08

WTC Cough Syndrom

• 1,402 either WTC or Lung Bill

• Projected Additional Pension costs =
$826 million - $104 million (F

• $723 million actual cost

urce: Niles, JK, Webber, MP, Gustave J, Zeig-Owens, R, Lee R, Glass L,
Weiden MD, Kelly KJ, & Prezant; Am Ind J Med: 9/2011

Lancet 9/3/2011

Lancet 2011; 378: 898-905

Department of Medicine

^RZeig-Owens MPH

T Schwartz MS, j Weakley M VW\

Department of Epidemiology

end Population Health

(M PWebber DrfH C E Hall PhD,

T E Rohan MBE^

HW Cohen DrPH]L. Department

of Pulmonary Medicine

<T K AUrfch M D, D J Prerant M D),

Department of Medicine,

Onoilogy (0 Dennan MDJl.

Albeit Einstein College of

Medicine Montefiore Medkal

Center, Bronx, NY, USA; and

Bureau of Health Service* Fire

Department of the City of New

Yorlc BrookrynNY, U5A

(RZeig-Owens, M PWebber,

T5chwartz,NJaberRFft-C

J Weakley, K Kelly MB-,

C, Pri'ant)

Correspondence ta

Dr MayriEWebber, Bureau of

Health Service* Fire Department

of the Crty of Hew York

3 Metnotech Center, Brookrya

NV 11201, USA

webbermg' fdny.nyc.gov

Early assessment of cancer outcomes In New York City
firefighters after the 9/11 attacks: an observational
cohort study

Rachel Zejg-Owens, AflayrJs P Webber, Charles B Hall r Theresa Schwartz, Madia Jaber r Jessica Weakley, Thomas E Rohan, HJJeJ W Cohen,
01 aa Dffman, Thomas K AIdrkh r Kerry tfeJJy, David j Prezant

Summaiy

Background The attacks on the World Trade Center [WTC] on Sept 11, 2001 (9/11) created the potential for
occupational exposure to known and suspected carcinogens. We examined cancer incidence and its potential
association with exposure in the first 7 years after 9/11 in firefighters with health information before 9/11 and
minimal loss to follow-up.

Methods We assessed 9353 men who were employed as firefighters on fan 1, 1996. On and after 9/11, person time for
8927 firefighters was classified as WTC exposed; all person-time before 9/11, and person time after 9/11 for 926 non-
WTOexposed firefighters, was classified as non-WTC exposed, Cancer cases were confirmed by matches w itli state
tumour registries or through appropriate documentation. We estimated the ratio of incidence rates in WTC exposed
firefighters to non-exposed firefighters , adjusted for age, race and ethnic origin, and secular trends, with die US
National Cancer Institute Surveillance Epidemiology and End Results (SEER) reference population. Cls were
estimated with overdispersed Poisson models. Additional analyses included corrections for potential surveillance bias
and modified cohort inclusion criteria.

Findings Compared with the general male population in die USA with a similar demographic mix, the standardised
incidence ratios (SIRs) of the cancer incidence in WTGexposed firefighters was 1 10 (95% CI 98-1 25). When
compared widi non- exposed firefighters, the SIR of cancer incidence in WTC- exposed firefighters was 1-19 {95% CI
0-96-1 -47) corrected for possible surveillance bias and 1-32 (1 07-1 -62) without correction for surveillance bias.
Secondary analyses showed similar effect sizes.

Interpretation We reported a modest excess of cancer cases in die WTC -exposed cohort. We remain cautious in our
interpretation of diis finding because die time since 9/11 is short for cancer outcomes, and the reported excess of
cancers is not limited to specific organ types. As in any observational study, we cannot rule out the possibility that
effects in the exposed group might be due to unidentified confounders. Continued follow-up will be important and
should include cancer screening and prevention strategies.

FDNY Study Cohort (n=9,853)

Study period 1/1/1996-12/30/2008
Active (not retired) on 1/1/1996
White, black, or Hispanic males

Known WTC exposure StatUS (exposed or non-
exposed)

Were or would have been < 60 on 9/11

Data Collection

Linked to state cancer registries in New York,
Florida, Pennsylvania, North Carolina and Virginia
(Actives are required to live in NYS)

- Match on various identifying factors such as:

• Social Security Number (100% of our cohort)

• First and Last Name

• Date of Birth

- Over 90% of those who are currently retired

Self-reported cases from Questionnaires verified

Two Comparison Groups

External - US male population using SEER-13

We used SEER rates to calculate expected cancers by
age group, gender, race and calendar year because
nationally incidence rates have changed over time for
certain cancers (ex. increases in thyroid, prostate &
melanoma)

Internal - Non-WTC exposed FDNY firefighters

Better control for background occupational exposures
of firefighting, lifestyle & other confounders. Note, in
the future, NIOSH may be able to provide a non-

Standardized Incidence Ratios
(SIRs)

SIR

Observed Number of Cases

Expected Number of Cases

(SEER)

SIR ratio

Exposed SIR

Unexposed SIR

Correcting Potential Surveillance Bias

We flagged 25 records for potential surveillance bias:

- 15 firefighters who had surveillance chest CT scans 6
months or less before a cancer diagnosis (lung, liver,
thyroid, non-Hodgkin lymphoma, and kidney).

- 10 firefighters diagnosed with prostate or hematologic
cancers within 6 months of routine FDNY blood tests

We then performed additional analyses in which we delayed the
diagnosis date by two years [SIR 1.21] or delayed the date
beyond 2008 [SIR 1.19] and compared the results to those
obtained using the actual diagnosis date [SIR 1.32].

Compared tumor staging by pre vs. post-9/11

Lancet 9/3/2011

Observed

Expected

SIR (95% CI)

All sites

Exposed (61884 person-years)
Non-exposed (60 7 61 person-years)
SIR ratio*

^"263

^38^

110(0 98-1-25) <
84(0-71-0-99)
132(107-1-62) ^

4

135

161

All sites (corrected)!

Exposed
Non-exposed
SIR ratio*

242
135

238
161

102(0-90-1-15)
0-84 (0-71-0-99)
1-21(0-98-149) <

Note: After correction for potential surveillance bias, Too few cases
to achieve statistical power for any individual cancer analysis.

Specific Cancer Results

Hodgkin's lymphoma

Exposed

2

■ ■

Non-exposed

<S

2

0-82 (0-20-3 27)

SIR ratio*

-

•■

■■

Exposed

21

13

1-58 (103-2-42)

Non-exposed

9

11

0-83 (0-43-1-60)

SIR ratio*

■• ••

■ *

1-90 (0-87-4-15)

Non-Hodgkin lymphoma

Exposed

Non-exposed

SIR ratio*

Non-Hodgkin lymphoma (corrected)t

Exposed

Non-exposed

SIR ratio*

Multiple myeloma

Exposed

Non-exposed

SIR ratio*

Leukaemia

Exposed

20

13

1-50(0 97-2-33)

Non-exposed

9

11

0-83 (0-43-1-60)

SIR ratio*

"

■■

1-81 (0 82-3 97)

Exposed

9

6

1-40(0 73-2-70)

Non-exposed

7

5

1-47 (O63-3.40)

SIR ratio*

J L

■ *

0-98 (0-33-2-77)

Lancet 9/3/2011

Points estimate (95% CI)

Expanded cohort]

Multiple primary cancers

Hazard ratio incident cancers

Late period

Early period

Corrected after 2008 incident cancers

Corrected incident cancers

Primary cohort (incident cancers)

137(112-168)
1 30 (1-06-159)
129(104-160)

1-34(1-07-1*7)
1-28(0-99-1-67)
1-19 (0-96-1*47)
121(0 98-149)
1 32 (1-07-1-62)

~l I I I I

OS 07 09 11 1-3 1-5 17 19

Figure; Primary and secondary analyses displaying point estimates and 95% CIs for all cancer sites combined

Primary cohort (corrected after 2003 incident cancers): standardised incidence ratios (SIRs) ratio of first cancers in
Wo rid Trade Center (WTC) exposed firefighters versus non-exposed firefighters. Corrected i ncldent cancers: SIR ratio
of fi rst cancers in exposed versus non-exposed fi refighters, with the diag nosis date delayed by 2 years for 25 cases,
which might have been detected by FDIMY screening. Corrected after 2008 incident cancers: SIR ratio of first cancers
in exposed versus non-exposed fi refighters with diagnosis dates delayed to beyond 2008 r the study period, for
25 cases that might have been detected by FDNY screening. Early period: SIR ratio of exposed firefighters in the early
follow-up period (Sept 11, 2001 [9/11 ] r to Dec 3L 2004) after 9/H versus no n- exposed firefighters, Late period:
SIR r at i o of exposed firefighter s in the late follow-up period (Jan 1 P 2005. to Dec, 31, 2008) after 9/11 versus
non-exposed firefighters. Hazard ratio incident cases: ratio of hazard- ratio rates of first cancers in exposed firefighters
versus no n- exposed firefighters estimated with the Cox model. Multiple primary cancers: SIR ratio of multiple
pri mary ca nee rs in exposed fi refi g hters versu s n on -exposed fi refig hte rs. Expa nded co ho rt : S I R rat i o of fi rst ca nee rs i n
exposed firefighters versus non-exposed firefighters including those who began employment between Jan 1, 1996,,
and Sept 10 r 2001

Hypotheses for biologic plausibility

• Presence of known carcinogens at WTC

• PAH, PCBs, Dioxins, Benzene related to hematologic
cancers (shortest latency)

• Esophageal Cancer related to GERD

• Testicular and prostate cancer related to combustion
byproducts and fine particulates

• Malignant mesothelioma related to asbestos

• Chronic Inflammation

• WTC exposure is a known cause of acute & chronic
inflammatory illnesses, (asthma, COPD, sinusitis, GERD).

• Crhonic inflammation in turn has been associated with
various cancers (non-Hodgkin lymphoma, prostate,
thyroid, melanoma)

Conclusions WTC and Cancer

There may be an early signal that Cancer and
WTC exposure are associated

Future work needs to

- Study additional populations

- Study all groups for longer amounts of time
(studies in the future)

WTC-Related Disease
Where Are We Now?

RESEARCH:

Zadroga Act

-NIOSH Federal WTC Research Program

Increased funding:

- Beyond case studies & cross-sectional analyses
-Stress collaboration and peer-review

- Basic science, mechanisms, can now be explored
Problems that require immediate solutions

-Can disease surveillance for NEW illnesses be done?
-Can time-critical research be done?
-Can peer-review be done effectively?

WTC-Related Disease
Where Are We Now?

RESEARCH:

Problems with immediate solutions

-Can disease surveillance for NEW illnesses be done?

-Can time-critical research be done?

- Data centers linked to clinical centers are the first to know
and can perform clinical and epidemiologic research in the
most rapid and efficient manner

-Project Program Grant Awards should be used to continue
ana expanaupon this proven research process

-Career Investigator Awards should be used to provide
those who have demonstrated their ability to succeed.

- Individual Awards (R01) should be used for hypothesis
driven mechanistic research which is not as time sensitive
and which the data centers are not equipped to do.

WTC-Related Disease
Where Are We Now?

RESEARCH:

Awards based on peer-review

Should continue but across a level playing field

- Peer grading

-Study section meeting after peer grading

-Scores normalized and prioritized

Lessons Learned:

Pre-Disaster Health Baselines including pulmonary function
and mental health screening

Protect workers by training and education BEFORE disaster

Strict enforcement of worker protection laws at the disaster
site especially after initial rescue effort

Register all workers (electronic id cards) to know # exposed,
locations of exposure, times and durations

Restrict worker hours/exposure to hazardous environments

Integrated Programs work best - Monitoring, Treatment and
Research - each feeding and growing off each other

-friAnK YOU

f