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Full text of "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 



[plMfSBiTHfltdprgffi, 



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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 












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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 



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10 



100 



Particle Diameter (microns) 



1000 



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



FDNY WTC Monitoring & Treatment Program 











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* 9/11 WTC 










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