(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "WTC Mount Sinai School of Medicine Clinical Center"



World Trade Center Health Program 
(WTCHP) at Mount Sinai 



Laura Crowley, MD 
Assistant Professor 
Mount Sinai School of Medicine 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Aftermath of the September 1 1 World Trade Center (WTC) attack, a 
large number of people sustained potential exposures to: 

□ Smoke, dust, particulate matter, and a variety of toxins, 

including asbestos, pulverized concrete, glass fibers, polycyclic 
aromatic hydrocarbons(PAHs), and polychlorinated furans and 
dioxins 

Most common effects seen to date are respiratory and mental health 
consequences 

Long-term consequences of exposures are not yet known, and there 
remains concern about the potential for late-emerging diseases 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



WTCHP Responder Population 




"Traditional responders": 

•Firefighters 

•Paramedics 

•Law enforcement officers 




"Nontraditional" responders : 

•Construction workers 

•Laborers and clean-up workers 

•Telecommunications workers 

•Gas and electric workers 

•Transit workers 

•Public sector workers (DOT, Parks, etc) 

•Volunteers 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ram Description 



Clinical Centers of Excellence (CCE) and Data Center * 

Provide comprehensive clinical periodic monitoring 
examinations for eligible WTC responders and treatment 
for WTC related conditions 

Disseminate information about WTC health effects and 
programs available to responders, the public, and health 
care providers 

Collect standardized clinical information to identify and 
track WTC physical and mental health consequences 



Conduct disease surveillance 




'Consortium included National Program thru June 30th 2008 



MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Description of Cohort 




N= 27,449* 

86% Male 

Median Age= 38 

57% Whites, 11% Black, 1% Asian, 3% 
Other, 28% Unknown, 31% Hispanic 

83% Union Member 

Work Status: 81% Employee, 11% Volunteer 
8% Both 



Through 9/1 1/2010 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



■ Description of Cohort 




Occupation Totals in WTCHP responders (n=27,449)* 



14,UUU - 




























12,273(48%) 












12,000 - 


















10,000 - 


















8,000 


















6,000 
4,000 








5,956 (23%) 


























4,025(16%) 












2,000 
- 






I 






I 


1 ,794 (7%) 


1,128(4%) 


I 




I 


477 (2%) 

i 



Protective Services Construction 
or Military 



Electrical or Transportation or Other occupations Unemployed or 

telecommunication material movers retired 

repair workers 



^Through 9/1 1/2010 

Note: Data missing for 1 ,796 rescue and recovery workers 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Total Visit 1 Year to Date 




■ A total of 32,108 Visit 1 examinations have been completed with in the 
NY/NJ consortium (including the National Program) as of August 31 ,2011 



WTC SCREENING AND MONITORING PROGRAMS (including National Program) 
Visit 1-6 Ex animations through August 31, 2011 




WTCWVMSP* 

(7/3002 - 
6/2004) 


WTC MEDICAL MONITORING PROG-BAM (7/2004 - PRESENT) 


Visit 1* 


Visit 2 


Visit 3 


Visit 4 


Visit 5 


Visit 6 


Clinic 


Total 


YEAH 1 - 
YEAR 7 


YEARS 
(7/1/11 - 
present) 


YEAR 1 - 

YEAR 7 


YEARS 
(7/1/11 - 
present) 


YEAR 1 - 
YEAR 7 


YEARS 
(7/1/11 - 
present) 


YEAR1 - 
YEAR 7 


YEARS 
(7/1/11 - 
present) 


YEAR 1 - 
YEAR 7 


YEARS 
(7/1/11 - 
present) 


YEAR 1 - 
YEAR 7 


YEARS 
(7/1/11 - 
present) 


Mount Sinai 


3,324 


11,107 


ne 


12^95 


355 


7,333 


354 


4245 


230 


2,023 


193 


443 


253 


Queens 


525 


1,350 


20 


1,595 


26 


932 


4? 


506 


35 


195 


15 


23 


13 


LI - Port Jeff/ Islandia 


1,250 


ijaz 


£4 


374? 


£3 


2,316 


77 


1744 


34 


713 


73 


133 


30 


LI- Nassau 


EeUeuue/NYU 


161 


1,463 


13 


366 


25 


463 


29 


227 


27 


33 


20 


17 


9 


UMDNJ 


363 


1,227 


£ 


1,031 


19 


721 


16 


430 


33 


143 


31 


26 


19 


NY/NJ Consortium Total 


11,125 


19,435 


231 


19,886 


493 


12,820 


525 


7,152 


469 


3,157 


337 


702 


329 


National Program* * 


653 


659 




332 




9ti 
















TOTAL 


11,783 


20,094 


231 


20,268 


493 


12,916 


525 


7,152 


469 


3,157 


337 


702 


329 






Clinic 


Total Monitoring 

Program Exams 

(VI - V6) 


Total Screening and 

Monitoring Program 

Exams 

(VI - V6> 




Mount Sinai 


39,872 


4S,696 


Queens 


5,269 


5,794 


LI - Fort Jeff/ Islandia 


13,3S9 


14,639 


LT- Nassau 


Eellevue/NYU 


3,252 


3,415 


LMDXJ 


3,754 


4,117 


NY/NJ Consortium Total 


65,536 


76,661 


National Program* * 


1,137 


1,795 


TOTAL 


66,673 


78,456 























*The total numbers of MMP \ isit 1,2,3,4,5 and 6 exams rare self- reported by each CC, Long Island Year 2 totals (for \1 and V2) rare estimated by subtracting 

Year 1 exams from the total number of exams performed through June 2GQ6- 

The total number 0: MMP ^.Isit 2 exams, periormed in Year 1 rare taken fromPFT transmissions from each CC to the DCC 

** National Program numbers v^re coordinated through the DCC as of June 30, 2GQB. Effective July 1, 2008, Logistics Health Incorporated (LHI) is the XP dinical center vvith coordination provided by NIOSH 

'V.TC V/YM5P = vrodd Trade Center vrorker and Volunteer Medical Screening Program 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Publications 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



■Vtl'GAICAN JOURNAL 

OF 
WI>U!fTRJj\L HtWClNe 



Health Effects of World Trade Center Site Workers 



Stephen Levin, md." Robin Herbert, md, Gwen Skloot, md, Jaime Szeinuk, md, 

Alvin Teirstein, md, David fischler, md, Debra Milek, md, George Piligian, md, 

Elizabeth VVilk -Rivard, md, and Jacqueline Moline, md 



LESSONS LEARNED 

While, a thorough analysis of the clinical, preventive, 
and other public health issues that emerged in the aftermath 
of the WTC disaster remains to be carried out, some 
questions/policies already suggest themselves as warranting 
attention. 



The importance of an advisory to health care providers 
ASAP to assist with their evaluation and clinical mana- 
gement of the physical and psychological problems 
WTC-related patients experienced. 
Immediate capture of registry (contact) information for 
volunteers and workers. 

Rapid distribution of appropriate respiratory protection 
and a peer-based structure for encouraging consistent use. 
Rapid mobilization of resources for pro -active medical 
evaluation/treatment — respiratory, musculoskeletal, and 

psychological — during the weeks following exposure at 
the disaster site. 

Testing of indoor settings, including analysis of settled 
dust and aggressive air monitoring, to establish a gradient 
of exposure with distance from Ground Zero to guide 
recommendations regarding clean-up and reoccupancy. 
Communication by public health agencies regarding 
exposure hazards in lay language, with focus not only 
on long-term cancer risks, but on short-term health 
consequences as well. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



mm 




Morbidity and Mortality Weekly Report 



Weekly 



September 10, 2004 / Vol. 53 / No. 35 



Physical Health Status of World Trade Center Rescue and Recovery Workers 
and Volunteers — New York City, July 2002-August 2004 

This report underscores the need for comprehensive occu- 
pational health assessment and treatment for rescue workers 
and volunteers as part of all emerge ncy preparedness programs. 
GuldeJ ines for professional emergency response workers have 
been developed (1). The results described in this report suggest 
that disaster preparedness also should include 1) planning for 
rapid provision of suitable respiratory and other protective 
gear and 2) provision of medical care for first responders and 
non traditional responders (e.g., persons from construction 
trades, utility workers, and other occupational groups). 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ENVIRONMENTAL 

HEALTH 

PERSPECTIVES 



Health and Environmental Consequences of the World Trade Center Disaster 

Philip J, Landrigan, 1 Paul J, Hoy, 2 George Thurston, 3 Gertrud Berkowitz, 1 LC, Chen, 3 Steven N, Chillrud, 4 
Stephen H Gavett, 5 Panos G, Georgopoulos, 2 Alison S, Gey h, 6 Stephen Levin,* Frederica Perera/ 
Stephen M Rappaport, 8 Christopher Small, 4 and theNIEHS World Trade Center Working Group* 

The attack on the WoHd Trade Center (WTC) created an acute environmental disaster of enormous 
magnitude. This study characterizes the environmental exposures resulting from destruction of the 
WTC and assesses their effects on health. Methods include ambient air sampling; analyses of out- 
door and indoor settled dust; high-altitude imaging and modeling of the atmospheric plume; inhala- 
tion studies of WTC dust in mice;; and clinical examinations, community surveys, and prospective 
epidemiologic studies of exposed populations. WTC dust was found to consist predominantly (95%) 
of coarse particles and contained pulverized cement, glass fibers, asbestos, lead, polycyclic aromatic 
hydrocarbons (PAHs), poJvchlorinated biphenvls (PCBs), and poK-chlorinated rurans and dioxins, 
Airborne particulate levels were highest immediately after the attack and declined thereafter. 
Particulate levels decreased sharply with distance from the WTC. Dust pH was highly alkaline 
(pH 9.0-1 LD). Mice exposed to WTC dust showed only moderate pulmonary inflammation but 
marked bronchial hyperreactivity. Evaluation of 10. 1 16 firefighters showed expo sure- related 
increases in cough and bronchial hyperreactivity. Evaluation of L&3 cleanup workers showed new- 
onset cough (33%)* wheeze (13%)s and phlegm production (24%). Increased frequency of new- 
onset cough, wheeze, and shortness of breath were also observed in community residents. 
Follow-up of 182 pregnant women who were either inside or near the WTC on 1 L September 
showed a 2-fold increase in smaJi-for-gestational-age (SGA) infants. In summary, environmental 
exposures after the WTC disaster were associated with significant adverse effects on health. The 
high alkalinity of WTC dust produced bronchial hyperreactivity, persistent cough, and increased 
risk of asthma. Plausible causes of the observed increase in SGA infants include maternal exposures 
to PAH and particulates. Future risk of mesothelioma may be increased, particularly among work- 
ers and volunteers exposed occupational ly to asbestos. Continuing follow-up of all exposed popula- 
tions is required to document the Jong-term consequences of the disaster. Key words: air pollution, 
airway hyperresponsiveness, asbestos, occupational lung disease, PM 2 ^ PM 10 , small for gestational 
age (SGA). Environ Health Pmpect 112:731-739 (2004). doi:L0.123?/ehp.6702 available via 
http://dx.doi org/ [Online IS February 2004] 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ENVIRONMENTAL 

HEALTH 

PERSPECTIVES 



The World Trade Center Disaster and the Health of Workers: Five-Year 
Assessment of a Unique Medical Screening Program 

Robin Herbert, 1 Jacqueline Moiine, 1 Gwen Skioot, 2 Kristina Metzger, 1 Sherry Baron, 3 Benjamin Luff, 4 
Steven Markowitz, 5 iris Udasin, 6 Denis e Harrison/ Diane Stein, 1 Andrew Todd, 1 Paul Enright, 8 
Jeanne Mager Steiiman, 1 ^ Phiiip J, Landrigan, 1 and Stephen M, Levin 1 



Background: Approximately 40,000 rescue and recovery workers were exposed to caustic dust and 
toxic pollutants following the LI September 2001 attacks on the World Trade Center (WTC). 
These workers included traditional first responders, snch as firefighters and police, and a diverse 

population of construction, utility', and public sector workers. 

Methods: To characterize WTC-related health effects* die "WTC Worker and Volunteer Medical 
Screening Program was established. This multicenter clinical program provides free standardized 
examinations to responders. Examinations include medical, mental health, and exposure assessment 
questionnaires; physical examinations; spirometry; and chest X rays. 

RESULTS: Of 9,442 responders examined between July 2002 and April 2004, 69^a reported new or 
worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of 
examination in 59% of these workers. Among those who had been asymptomatic before 
September 1 L, 61% developed respiratory symptoms while performing WTC work. Twenty -eight 
percent had abnormal spirometry! forced vital capacity {FVC) was low in 21%i and obstruction was 
present in 5%. Among nonsmokers* 27% had abnormal spirometry compared with 13% in the 
general U.S. population, Prevalence of low FVC among nonsmokers was 5-fold greater than in the 
U.S. population (20% vs. 4%). Respiratory symptoms and spirometry abnormalities were signifi- 
candy associated with eady arrival at the site. 

Conclusion": WTC responders had exposure-related increases in respiratory symptoms and pul- 
monary function test abnormalities that persisted up to 2.5 years after the attacks. Long-term medical 
monitoring is required to track persistence of these abnormalities and identify late effects, including 
possible malignancies. Lessons learned should guide future responses to civil disasters. 

Key words i air pollution, disaster response, occupational lung disease, pulmonary function, 
September 1 I, spirometry, Worid Ttade Center. Emuvn Htdth Ptrspect 1 14:1853-1858 (2006). 
doi: 10. L289/ehp,9592 available via hup:ttdx,dolor$ [Online 6 September 2006] 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Tournal of (Occupational and 
*~T7nvironmental A/ledicine 

Air Trapping Detected on End-Expiratory 
High-Resolution Computed Tomography in 
Symptomatic World Trade Center Rescue and 
Recovery Workers 

David S. Mendelson, MD 

Mark Roggeveen, MD 

Stephen M. Levin, MD 

Robin Herbert, MD 

Rafael E. de la Hoz, MD, MPH, MSc 

Ohjecth>es: We utilized end-expiratory chest computed tomography (CT) to 
investigate air trapping (AT) in symptomatic former World Trade Center 
(WTCf workers, and correlated the findings with clinical, physiological, and 
exposure-related characteristics. Methods: Twenty-nine \VTC workers with 
lower respiratory symptoms were evaluated. CUnicol data included symptom 
inventories > quantitative respiratory symptom scores^ \VFC dust exposure 
duration, pulmonary function tests* and inspiratory and end-expiratory 
high-resolution chest CT scanSu The latterwerescoredquantitaiii&lyforATfby 
two methods) and interstitial changes, and those scores were correlated with ttie 
clinical data. Results: 77m 7 tu*o AT scoring methods yielded highly correlated, 
results, AT was demonstrated in 25 of 29 patients* with scores ranging from 
to 24 (mean, 10. 6). There was a statistically significant correlation between 
AT and. the duration of dust exposure, AT scores were sigiiificantly higher in 
patients with restricthte lung junction data., and in lifetime nonsmokers. 
Conclusions: Our dato suggest that AT from small airways disease may 
account for some of the reported clinical and. pulmonary functional abnor- 
malities in H'TH dusfexposed urorkers^ and support tJie use of high^resolution 
CT scans in the initestigation and characterization of the pulmonary ailments 
of selected workers, (J Occup Environ Med, 2QQ7;49?34Q~S45) 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



AAL1ULICAN JOURNAL 

OF 

JfJl>USTtJj\I, HKIHCINe 




Vocal Cord Dysfunction in Former World Trade 

Center (WTC) Rescue and Recovery 

Workers and Volunteers 



Rafael E. de la Hoz, md, mph, k Michael R. Shohet, hd, z+ Laura A. Bienenfeld, wd, i + 
Abodbd A. Afilaka, hd, 3+ Stephen M. Levin, ho, 3 - and Robin Herbert, md 2: 



Bac kgruimd Sfocal cord dysfunction fVCD) is a condition characterized by paradoxical 

l?artial adduction of the vocal cords on insp iration. It has l?een associated with exf?osures to 
irritants, as well as with psychological illnesses and conditions. Workers who participated 
in the recovery of the WTC disaster site wereex$?osedto a large amount of irritants as well 
as consideraI?le [?sychoiogical stressors. We describe the clinical characterises of 
10 symptomatic former WTC workers diagnosed with this condition, as well as the 
frequency of spirome trie findings suggestive of variable extraihoracic obstruction. 
Me Ihods Wo rke rs who Income symptomatic afte r their WTC work exi?e rience ha ve i?een 
evaluated clinically by a multidisciplinary team at an academic medical center. The 
e valuation included history, physical exam ination, chest radio growth, blood tests, andp re - 
and iM?st-bronchodUator spirometry in all patients. Additional evaluations and diagnostic 
tests included otoiaryngological evaluation with flexible rhinolaryngoscopy and strobo- 
scopy, gastroenterological and psychiatric evaluations. A randomly selected sample of 
172 spirometry results were re vie wed for evidence of inspiratory flow limitation. 
Results Variable extrathoracic oi?struction was found in 13.6% of the spin?me tries. Ten 
l?atients were diagnosed with VCD. In addition to symptoms suggestive of co-morbid 
conditions ^particularly rhinitis and acid refiux disease), most of the 10 patients had 
{1} hoarseness, (2) dyspnea that was not associated with bronchial hyperreactivity, or 
(3) dyqtnea associated with asthma, with either mild bronchial hyperreactivity and/or 
l?oor req?onse to asthma treatment. 

CondiisKins VCD appears to l?e j?art of the s^?ectrum of airway disorders caused by 
occupational exposures at the WTC disaster site. Further study of this association is 
warranted Am. J. IndL Med. 51: 16 1- i 65, 2008. S> 2008 Witey-Uu. Inc. 

KEY WORDS: occupational medicine; inhalation injury; vocal cord dysfunction; 
asthma; respiratory diseases; irritant exposures 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



MOUNT SINAI 
JOURNAL OF MEDICINE 



WTC Medical Monitoring and 

Treatment Program: 

Comprehensive Health Care Response in 

Aftermath of Disaster 

Jacqueline M. Moline, MD, MSc, L Robin Herbert, MD, 1 Stephen Levin, MD, 1 

Diane Stein, BS, 1 Benjamin J. Luft, MD, 2 Iris G. UdasLn, MD 3 and Philip 

J. Landrigan, MD t MSc 

ABSTRACT 

Ine attack on the World Trade Center (WTC) on 
September 1 1th, 2001 exposed thousands of individ- 
ual? to an unprecedented mix of chemicals, combus- 
tion products and microni/.ed building materials. 

Clinicians at the Mount Sinai Irvine, -SelikofT Cen- 
ter for Occupational and E[nvironmental Medicine, in 
partnership with affected stakeholder organizations, 
developed a medical screening program to evalu- 
ate the health status of workers and volunteers who 
spent time at the WTC site and thus sustained expo- 
sure in the aftermath of September 1 1th. Standardized 
questionnaires were adapted for use in this unique 
population and all clinicians underwent training to 
ensure comparability. 

The WTC Worker and Volunteer Medical 
Screening Program (MSI ] ) received federal funding in 
April 2002 and examinations began in July 2002. r l1ie 
MSI ] and the follow up medical monitoring program 
has successfully recruited nearly 22,000 responders. 
and serves as a model for the rapid development of 
a medical screening program to assess the health of 
populations exposed to environmental hazards as a 
result of natural and man-made disasters. 

Trie MSP constitutes a successful screening 
program for WTC responders. We discuss the 
challenges that confronted the program; the absence 
of a prior model for the rapid development of a 
program to evaluate results from mixed chemical 
exposures- Little documentation of the size of the 
exposed population or of who might have been 
exposed- and uncertainty about both the nature and 
potential severity of immediate and long-term health 
effects. Mi Sinai f Med 75*67-7% 20Q&. © 20OS 
Mourn Sinai School of Medicine 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ENVIRONMENTAL 

HEALTH 

PERSPECTIVES 



Enduring Mental Health Morbidity and Social Function Impairment 
in World Trade Center Rescue, Recovery, and Cleanup Workers: 
The Psychological Dimension of an Environmental Health Disaster 

Jeanne Mager Steiiman, 12 Rebecca P. Smith, 1 Craig L Katz, 1 Vansh Sharma, 1 Dennis S, Charney, 1 Robin Herbert 3 
Jacqueline Moiine, 3 Benjamin J, Luft, 4 Steven Nlarkowitz, 5 iris Udasin, 6 Denise Harrison/ Sherry Baron, 8 
Phiiin J, Landrigan, 3 Stephen M, Levin, 3 and Steven Southwick 19 



BACKGROUND: The World Trade Center (WTC) attacks exposed thousands ofworkers to hazardous 
environmental conditions and psychological traum a In 2002 n to assess the health of these workers. 
Congress directed the National Institute for Occupational Safety and Health to establish the WTC 
Medical Monitoring and Treatment Program. This program has established a large cohort of WTC 
rescue recovery, and cleanup workers. We previously documented extensive pulmonary dysfunc- 
tion in this cohort related to toxic environmental exposures. 

OBJECTIVES: Our objective in this study was to describe mental health outcomes, social function 
impairment, and psychiatric comorbidity in the WTC worker cohort* as well as perceived sympto- 
matology in workers 7 children. 

Methods: Ten to 61 months after the WTC attack. 1 n 1 32 WTC workers completed a self- 
administered mental health questionnaire. 

RESULTS: Of the workers who completd the questionnaire, 11 J% met criteria for probable post- 
traumatic stress disorder (PTSD). 8.8% met criteria for probable depression, 5^0% met criteria for 
probable panic disorder, and 62% met criteria for substantial stress reaction. PTSD prevalence was 
comparable to that seen in returning Afghanistan war veterans and was much higher than in the U.S. 
general population. Point prevalence declined from 135% to 9 7% over the 5 years of observation. 
Comorbidity was extensive and included extremely high risks for impairment of social function. 
PTSD was significantly associated with Loss of family members and friends, disruption of family, 
work, and social life, and higher rates of behavioral symptoms in children of workers, 

CONCLUSIONS: Working; in 9/1 L recovery operations is associated with chronic impairment of men- 
tal health and social functioning. Psychological distress and psychopathology in WTC workers 

gready exceed population norms. Surveillance and treatment programs continue to be needed. 

KEYWORDS: depression, disaster wo rkers n functional impairment,, occupational health* post- 
traumatic stress disorder stress, World Trade Center. Environ He/ihh Ptrspect 1 16: 1248^1253 

(2008). doi:10.1289/ehpJ 1 164 available via httpr/fdx.rfoLorg? [Online 1 1 May 2008] 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 




Journal of (Occupational and 
^Environmental A/ledicine 

Reflux Symptoms and Disorders 
and Pulmonary Disease in Former World 
Trade Center Rescue and Recovery Workers 
and Volunteers 

Rafael E. de la Hoz 9 MD, MPH 
Jennifer Christie, MD 
Jelani A. Teamer 
Laura A. Bienenfeld, MD, MPH 
Aboaba A. Afilaka, MD, MPH 
Michael Crane, MD 
Stephen M. Levin, MD 
Robin Herbert, MD 

Background: (Gastroesophageal, reflux disease is one of the most preivilent conditions 
among former World Trade (lenier Irvl'Q rescue and recovery markers. The reason for this 
prfrftosea association with an inhalation injury is unclear. In this study, we clinically 
characterized ihe reflux disorder* iu former Wl t a *orkers, and nv investigated their asscfciation 
with pulmonary Junction abnormalities and with clinical diagnoses of other WFX^related 
diseases. Methods: Torty-tm) former W1C workers unden&eni the follo&vng testing: symptom 
inventories; physical examination, spircfmetry, esttphag^stroduoaenoscofrf, and 24-hour pi I 
monitoring studies for the evaluation of chronic jrflux-Bke symptoms. Patients were classified 
into two groups based on clinical nrafuaiion: group 1 (reflux paiienls) including definitiiK 
reflux disorders (gastroesophageal reflux, nanerosrw reflux, nonacid reflux, and laryn^pha- 
ryjjgeal reflux diseases} and group zfnorvflux patients) patienis without dinicatty significant 
reflux disease, including functional heartburn, and hypersensitiire esophams disorder. Results: 
The reflux and no-reflux patienis had significantly different fohnson-ljeMeester scores find 
esophageal acid exposure times. Patients with reflux disorders urre more likely to hate reduced 
forced vital capacity (% 2 = 5. 49, P = 0.031) and also more likely to have been diagnosed with 
a fruitfT- airway disease (x 2 = 7. 14 P = 0.00&}. We found no significant association betaaen 
reflux and psychiatric disorders (x* = 0.02, P = 0.S9), levels of exposure at the Wl'C site, or 
incidence of dry cough, or other upper airiiWi disorders, Conclusions: A spectrum of reflux 
symptoms and disorders are present, m WFC responders. Our data mggest that the presence of 
reflux disease is related to that of pulmonary function abnormality suggestive of air trapping mount sinai 

and a diagnosis of a ioww respiratory disease. (J Occup Environ Med. 2QQ&;5u: school of 

1351-135$ MEDICINE 




CHEST 

G "Hi Li a I publication af th« Amtrlcan C allege af Chest Fhytlcians 

Longitudinal Assessment of Spirometry 
in the World Trade Center Medical 
Monitoring Program* 

Gwen S. Skhot, MD; Chjde B. Sehechter, MD; Rolnn Herbert, MD: 
Jacqueline M. Moline., MD; Stephen M. Levin, MD: L&um E. Crowley, MD; 
Benjamin j Lufi, MD; his G. Udasin; and. Paul L. Enright, MD, FCCF 



Background; Multiple studies na^e demonstrated an initial nigh prevalence of spirometric 
abnormalities following World Trade Center (WTC) disaster exposure. We assessed preva- 
lence of spirometric abnormalities and changes in spirometry between baseline and first 
follow-up evaluation in par tieip ants in the WTC Worker and Volunteer Medical Monitoring 
Program, We also deter mined tbe predielors of spirometric change between the two 
examinations. 

Method**: Prchronchodilator and posthronchodilator spirometry', demographies, occupational 
history, smoking status, and respiratory symptoms and exposure onset were obtained at both 
examinations {about 3 years apart). 

fhCKoita: At the second examination, 24 A% of individuals had abnormal spirometry findings. 
The predominant defect was a low FVC without obstruction (I6\l*£). Between examinations^, 
the majority of individuals did not have a greater -than -expected decline in lung function. The 
mean decline h in prchronchodilator FEV| and FVC were 13 diL/jt and 2 mL/yr* respectively 
(postbronchodilator result h were similar and not reported) ■ Significant predictors of greater 
average decline between examinations were bronehodilator responsiveness at examination t 
and weight gain, 

Co pic hwians: Elevated rates of spirometric abnormalities were present at both examinations, 
with reduced FVC most common. Although the majority had a normal decline in lung 
function,, initial bronehodilator response and weight gain were significantly associated with 
grealcr-than- normal lung function declines. Due to the presence of spirometric abnormali- 
ties > 5 years after the disaster in many exposed individuals, longer-term monitoring of WTC 
res ponders is essential. (CHEST 2009; 135:492-498) 

Key words: bronehodilator response:, occupational Lung disease; spirometry;, weight gain; World Trade Center 

Abbreviations; H Ml = body mass index; LLN = lower limit of normal; El ADS = reactive airway dysfu action 
syndrome:, WTC = World Trade Center 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 




PSYCH 



_The 

Psychiatrist 

^ FORMERLY THE PSYCHIATRIC BULLETIN 

Psychiatric symptoms in Ground Zero ironworkers 
in the aftermath of 9/11: prevalence and predictors 



CRAIG L. KATZ, STEPHEN LEVIN, ROBIN HERBERT, SIMON MUNRO, ANAND PANDYA 
AND REBECCA SMITH 



AIMS AND METHOD 

To establish the prevalence of, and 
risk factors for, psychiatric symptoms 
in Ground Zero ironworkers. 
Questionnaires commonly used to 
screenfor psychiatric symptoms were 
completed by 124 workers. 

RESULTS 

We have established the prevalence 
of screening positive for symptoms of 
post-traumatic stress disorder, panic 
attacks, generalised anxiety, 
depression and alcohol misuse. 
Among the risk factors were alcohol 
misuse, injury to or death of a family 
member, friend or co-worker at 
Ground Zero and one or more adverse 
life events since 9/11. 

CLINICAL IMPLICATIONS 

Ironworkers at Ground Zero tend to 
have significant psychiatric symp- 
toms likely to be associated with the 
traumatic experience of working 
there during the clean-up operation. 
Risk factors for psychiatric symptoms 
were established. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 




Journal of (Occupational and 
^|7iwironmental A/Jedicine 

Multiple Myeloma in World Trade Center 
Responders: A Case Series 

Jacqueline M. Moline, MD, MSc 

Robin Herbert, MD 

Laura Crowley, MD 

Kevin Troy, MD 

Erica Hodgman, BA 

Gauri Shukla, MPH 

Iris Udasin, MD 

Benjamin Luft, MD 

Sylvan Wallenstein, PhD 

Philip Landrigan, MD, MSc 

David A. Savitz, PhD 

Object 'hies: We report on cases of multiple myeloma (MM) observed in 
World Trade Center (WFC) responders registered in the l\TC Medical 
Progmm. At ethods: Possible cases of MM diagnosed between September 

11, 2001, and September 10, 2007, in responders were confirmed if they 
met the World Health Organization and Mayo Clinic diagnostic 
criteria, Results: Among 28,252 responders of known sex and age, eight 
cases of MM were observed (6. S expected). Four of these cases time 
obsertwd in responders younger than 45 yean at the time of diagnosis 
(L2 expected), A slight deficit of MM cases was observed in responders 
older than 45 years (4 obsert*ed> 5.6 expected), Conclusion: In this case 
series, we observe an unusual number of MM cases in WTC responders 
under 45 years. This finding underscores the importance of maintain- 
ing surveillance for cancer and other emerging diseases in this highly 
exposed population. (J Occup Environ Med. 2009;51:896-902) mount sinai 

SCHOOL OF 
MEDICINE 




Psychiatric 
Quarterly 



Stories Behind the Symptoms: A Qualitative Analysis 
of the Narratives of 9/11 Rescue and Recovery Workers 



Corey B* Bills * Nancy Dudson * Jeanne M Slellman * Steven South wick * 
Vansh Sharma * Rubin Herbert ■ Jacqueline M* Muline * 
Crai^ 1.* Kal/ 

Abstract A qualitative study of the experiences of rescue and recovery workers/ volun- 
teers at Ground Zero following the terrorist attacks of 9/1 1/01 is reported. Information was 
extracted from a semi-structured clinical evaluation of 416 responders who were the initial 
participants in a large scale medical and mental health screening and treatment program tor 
9/11 responders. Qualitative analysis revealed themes that spanned four categories — 
occupational roles, exposures, attitudes/experiences, and outcomes related to the experi- 
ence of Ground Zero. Themes included details regarding Ground Zero roles, grotesque 
experiences such as smells, the sense of the surreal nature of responding, and a turning to 
rituals to cope after leaving Ground Zero, These findings personalize the symptom reports 
and diagnoses that have resulted from the 9/11 responders' exposure to Ground Zero, 
yielding richer information than would otherwise be available for addressing the psy- 
chological dimensions of disasters, This work shows that large scale qualitative surveil- 
lance of trauma-exposed populations is both relevant and feasible. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 




Journal of (Occupational and 
* - T7nvironmental ]V/Jedicine 

Snoring and Obstructive Sleep Apnea Among Former World 
Trade Center Rescue Workers and Volunteers 

Rafael K de la Hoe, MD, MPH, Rashmi N. Aurora, MD. Paul Landsbergis, PhD, Laura A. Btenenfeld, MD t MPH, 

Aboabu A. Ajifaka, MD, MPH, and Robin Herbert, MD 

Background: Snoring is a common svmplom among workers with adverse 
heaith effects from their WoTid Trade Center iWTCl occupational expo- 
sures. Rhinitis and upper airway disease are highly prevalent among Ihese 
worker. Rhinitis has been associated with snoring and. in some studies, 
with obstructive sleep apnea {OS A). We examined Hie association of WTC 
exposure and findings on nocturnal calYsomnoBram. as wel] as known 
predidors or OSA in this patient population. Mclhods] One hundred 
participants with snoring underwent a polysemnogram to exclude OS A. 
Comorbidities had been previously evaluated and treated. The apnea- 
hypopnea index iAHI) defined and categorized the severity of OSA. Age, 
sex, tody mass index iBMI). and WTC exposure variables were examined 
in bivariate and multiple reejession analyses, Results: Our sludy sample 
had a similar prevalence of five major disease categories, as we previously 
reported. OSA was diagnosed in 62% of the patients and was not associated 
with any of those disease categories. A trend toward increasing A HI with 
increasing. WTC exposure chirution failed 1o Teach the statistical significance 
(P = 0. 14 1 in multiple regression analysis. An elevated AHt was associated 
with BMI {P = 0.003 1 and male sex {F < 0.001 1. Conclusions: OSA was 
associated with EMI and male sot but no1 with ;s:cuparional WTC exposure 
indicators in this patient population. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ENVIRONMENTAL 

HEALTH 

PERSPECTIVES 



Case Report: Lung Disease in World Trade Center Responders 
Exposed to Dust and Smoke: Carbon Nanotubes Found in the Lungs 
of World Trade Center Patients and Dust Samples 

Maoxin Wu, 1 Ronald E. Gordon, 1 Robin Herbert 2 Maria Padilla, 3 Jacqueiine Motine, 2 David Mendelson, 4 
Virginia title, 5 * William D. Travis, 6 and Joan Gil* 

CONTEXT: After the collapse of the World Trade Center (WTC) on 1 1 September 2001 1 a dense cloud 
of dust containing high levels of airborne pollutants covered Manhattan and parts of Brooklyn,. New 
York Between 60,000 and 70,000 responders were exposed. Many reported adverse health effects. 

CASE PRESENTATION: In this report we describe clinical, pathologic, and inineralogic findings in 
seven previously healthy responders who were exposed to WTC dust on either 11 September or 
12 September 2001, who developed severe respiratory impairment or unexplained radiologic findings 
and underwent video-assisted thoracoscopic surgical Jung biopsy procedures at Mount Sinai Medical 
Center. WTC dust samples were also examined. We found that three of the seven responders had 
severe or moderate restrictive disease clinically. Histopathology showed interstitial lung disease con- 
sistent with small airways disease, bronchiolocentric parenchymal disease, and nonnecrotizing granu- 
lomatous condition. Tissue mineralogic analyses showed variable amounts of sheets of aluminum 
and magnesium silicates, chrysolite asbestos, calcium phosphate, and calcium sulfate. Small shards of 
glass containing mosdy silica and magnesium WTre also found. Carbon nanotubes (CNT) of various 
sizes and lengths were noted. CNT were also identified in four of seven WTC dust samples. 

DISCUSSION: These findings confirm the previously reported association between WTC dust expo- 
sure and bronchiolar and interstitial lung disease. Long-term monitoring of responders will be 
needed to elucidate the full extent of this problem. The finding of CNT in both WTC dust and 
lung tissues is unexpected and requires further study. 

KEY WORDS: bronchiolitis, carhon nanotubes, interstitial lung disease, small airway disease, WTC. 
Environ Health Perspect 1 18:499-504 {2010). doi:10.1289/ehp.0901 159 [Online 4 December 2009] 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



ENVIRONMENTAL 

HEALTH 

PERSPECTIVES 



Chemosensory Loss: Functional Consequences of the 
World Trade Center Disaster 

Pamela H, Dalton/ Richard E. Qpiekun, 2 Mich oh Gould 1 Ryan McDermott, 1 Tamika Wilson, 1 Christopher Maute, 1 
Mehmet H. Ozdener, ? Kai Zhao, 1 Edward Emmett, 3 Peter S.J. Lees/ Robin Herbert, 5 and Jacqueline Moline 5 



BACKGROUND! Individuals involved in rescue, recovery y demolition, and cleanup at the World 
Trade Center (WTC) site were exposed to a complex mixture of airborne smoke^ dust, combustion 
gases, acid mists, and metal fumes. Such exposures have the potential to impair nasal chemosensory 
(olfactory and trigeminal) function. 

OBJECTIVES The goal of this study was to evaluate the prevalence of chemosensory dysfunction and 
nasal inflammation among these individuals. 

METHODS: We studied 102 individuals who worked or volunteered at the WTC site in the days and 
weeks during and after 11 September 2001 (9/11) and a comparison group with no WTC exposure 
matched to each participant on age, sex> and job title. Participants were comprehensively evaluated 
for chemosensory function and nasal inflammation in a single session. Individual exposure history 
was obtained from self-reported questionnaires. 

RESULTS; The prevalence of olfactory and trigeminal nerve sensitivity loss was significantly greater 
in the WTC-exposed group relative to the comparison group [prevalence ratios (95% confidence 
intervals) = 1.96 (1.2-33) and 3.28 (2.7-3.9) for odor and irritation thresholds, respectively]. 
Among the WTC responders, however, individuals caught in the dust cloud from the collapse on 
9/11 exhibited the most profound trigeminal loss. Analysis of the nasal lavage samples supported 
the clinical findings of chronic nasal inflammation among the WTC-exposed cohort. 

CONCLUSIONS: The prevalence of significant chemosensory impairment in the WTC-exposed group 
more than 2 years after their exposure raises concerns for these individuals when the ability to detect 
airborne odors or irritants is a critical safety factor. 

RELEVANCE TO CLINICAL PRACTICE: This outcome highlights the need for chemosensory evaluations 
among individuals with exposure to acute high or chronic levels of airborne pollutants. 

KEY WORDS: chemosensation, inflammation, irritation, occupational exposure, olfaction, World 
Trade Center. Environ Health Perspect 118:1251-1256 (2010). doi:10.1289/ehp.l001924 [Online 
18 May 2010] 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



■VtlULICAN JOURNAL 
OF 

IUDLATRLVL HJ-UiCINe 




"Sarcoid Like" Granulomatous Pulmonary Disease 
in World Trade Center Disaster Responders 



Laura E. Crowley, md, 1 * Robin Herbert, md, 1 Jacqueline M. Moline, md, msc, 1 

Sylvan Wallenstein, PhD, 1 Gauri Shukla, mph, 1 Clyde Schechter, md, 2 Gwen S. Skloot, md, 1 

Iris Udasin, md, 3 Benjamin J. Luft, md, 4 Denise Harrison, md, 5 Mo she Shapiro, ms, 1 

Karen Wong, mph, 6 Henry S. Sacks, md, PhD, 1 Philip J. Landrigan, md, msc, 1 and 

Alvin S. Teirstein, md 1 



Background More than 20,000 responders have been examined through the World Trade 
Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. 
Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of 
this study was to report the incidence of "sarcoid like " granulomatous pulmonary disease 
in other WTC responders. 

Methods Cases of sarcoid like granulomatous pulmonary disease were identified by: 
patient self- re port, physician report and I CD -9 codes. Each case was evaluated by three 
pulmonologists using the ACCESS criteria and only "definite" cases are reported. 
Results Thirty-eight patients were classified as "definite" cases. Six-year incidence was 
1 92/1 00, 000. The peak annual incidence of 54 per 1 00, 000 person -years occurred between 
9/1 1/2003 and 9/1 1/2004. Incidence in black responders was nearly double that of white 
responders. Low FVC was the most common spirometric abnormality. 
Conclusions Sarcoid like granulomatous pulmonary disease is present among the WTC 
responders. While the incidence is lower than that reported among firefighters, it is higher 
than expected Am. J, Ind. Med. 54:175-184, 201 1. © 2010 Wiley-Liss, Inc. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



■Occupational and 
I Environmental Heafth 



Odor identification ability and self-reported upper respiratory 
symptoms in workers at the post-9/11 World Trade Center site 



K flint tli W. Alt man * Sliaun V. Dcsai * J a c que lint .\ Inline * Rafael E. de La Huz 
Rubin Herbert * Patrick J. Gannon * Richard L. Duty 

Abstract Following the World Trade Center (WTC) 
collapse on September 1 1, 2001, more than 40,G30 people 
were exposed to a complex mixture of inhalahle nano par- 
ticles and toxic chemicals. While many developed chronic 
respiratory symptoms, to what degree olfaction was com- 
promised is unclear. A previous WTC Medical Monitoring 
and Treatment Program study tbund chat olfactory and 
nasal trigeminal thresholds were altered by the toxic 
exposure, hat not scores on a 20- odor smell identification 
test. 

Objectives To employ a well -validated 40 -item smell 
identification test to definitively establish whether the 
ability to identify odors is compromised in a cohort of 
WTC -ex posed individuals and, if so, whether the degree of 
compromise is associated with self-reported severity of 
rhinitic symptoms. 

Methods The University of Pennsylvania Smell Identifi- 
cation Test (UP SIT) was administered to 99 WTC-ex posed 
persons and 99 matched normal controls. The Si no- Nasal 
Outcomes Test (SNOT -20) was administered to the 99 
WTC-ex posed persons and compared to the UP SIT scores. 
Results The mean (SD) UP SIT scores were lower in the 
WTC-ex posed group than in age-, sex-, and smoldng his- 
tory-matched controls | respective scores: 30.05 (5.08) vs 
35.94 (3.76);/? = 0.003], an effect present in a subgroup of 
19 subjects additionally matched on occupation (/? < 
0.0G I ). Fifteen percent of the exposed subjects had severe 
microsmia, but only 3% anosmia. SNOT -20 scores were 
unrelated to UPSIT scores (r = 20;/? = 0.1 I). 
Conclusion Exposure to W r TC air pollution was associ- 
ated with a decrement in the ability to identify odors, 
implying that such exposure had a greater influence on 
smell function than previously realized. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



THE LANCET 

Persistence of multiple illnesses in Wo rid Trade Center rescue 
and recovery workers: a cohort study 

Juan P WJsnJuesfcy r Susan! Teitelbauni Andrew CJoda\ Paolo EoffeU-a, Michael Crane, Laura CiavAe% Rafael Edela Hoi r Cornelia Dellenbauah, 
BenkeHairkm, Robin Herbert, Hyuf] Kim r Y\mhti>Jeof] r Julia Kaplan, Craiq Katz r Stephen Levin, Ben Luft- r Steven MarkDwit.z r 
Jacqueline M Moline r Fatih Oibay r Robert H Pietnak, Mosfre Shapiro, Vansh 5hiirnri£i r GwejrSJtfDDt r Steven 5outhwJc£ r LariA Stevenson, 
Iris Udasfji r S^Jvan WaJTenstfj"n r Philip J Landiiqar] 

Summary 

Background More than SO 000 people participated in the rescue and recovery work that followed the Sept 11, 2001 
(9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in die early 
years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 
9 years since die attacks, examine their associations with occupational exposures, and quantify physical and mental 
health comorbidities. 



Methods In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 
27 449 participants in the WTC Screening, Monitoring, and Treatment Program, The study population included police 
officers, firefighters, construction workers, and municipal workers. We used the Kaplan- Meier procedure to estimate 
cumulative and annual incidence of physical disorders (asdima. sinusitis, and gastn> oesophageal reflux disease), 
mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric 
abnormalities. Incidence rates were assessed also by level of exposure {days worked at the WTC site and exposure to 
the dust cloud). 

Findings 9-year cumulative incidence of asthma was 27 ■ 6% {number at risk: 7027), sinusitis 42-3% (5870), and gastro- 
oesophageal reflux disease 39-396 (5650). In police officers, cumulative incidence of depression w r as 7-0% (number at 
risk: 3648), PTSD 9-3% (3761), and panic disorder 8 4% (3780). In other rescue and recovery workers, cumulative 
incidence of depression was 27-596 (number at risk: 4200), PTSD 31-9% (4342), and panic disorder 21 296 (4953). 
9-year cumulative incidence for spirometric abnormalities was 41-8% [number at risk: 5769); three-quarters of these 
abnormalities were low forced vital capacity. Incidence of most disorders was highest hi workers with greatest WTC 
exposure. Extensive comorbidity was reported with in and between physical and mental health disorders. 

Interpretation 9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden 
of physical and mental health problems. These findings emphasise die need for continued monitoring and treatment 
of the WTC rescue and recovery population. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



List of Publications -to- date 



11. 

12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 



Levin S, Herbert R, Skloot G, Szeinuk J, Teirstein A, Fischler D, Milek D, Piligian G, Wilk-Rivard E, Moline J. "Health Effects of World Trade Center Site Workers". 
Am J Ind Med. December 2002; 42(6):545-547. 

Berkowitz GS, Wolff MS, Janevic TM, Holzman IR, Yehuda R, Landrigan PJ. "The World Trade Center Disaster and Intrauterine Growth Restriction". JAMA. Aug 
2003;290(5):595-596. 

Skloot G, Goldman M, Fischler D, Goldman C, Schechter C, Levin S, Teirstein A. "Respiratory Symptoms and Physiologic Assessment of Ironworkers at the World 
Trade Center Site". Chest, April 2004; 125(4): 1248-1255. 

Levin SM, Herbert R, Moline JM, Todd AC, Stevenson L, Landsbergis P, Jiang S, Skloot G, Baron S, Enright P. "Physical Health Status of World Trade Center 
Rescue and Recovery Workers and Volunteers- New York City, July 2002 - August 2004". MMWR Morb Mortal WklyRep. September 2004;53(35): 807-812. 
Smith, RP, Katz CL, Holmes A, Herbert R, Levin S, Moline J, Landsbergis P, Stevenson L, North C, Larkin GL, Baron S, Hurrell Jr JJ: "Mental Health Status of World 
Trade Center Rescue and Recovery Workers and Volunteers - New York City, July 2002 - August 2004". MMWR Morb Mortal Wkly Rep. September 2004;53(35): 
812-815. 

Landrigan PJ, Lioy PJ, Thurston G, Berkowitz G, Chen LC, Chillrud SN, Gavett SH, Georgopoulos PG, Geyh AS, Levin S, Perera F, Rappaport SM, Small C; 
"NIEHS World Trade Center Working Group. Health and Environmental Consequences of the World Trade Center Disaster". Environ Health Perspect. May 
2004;1 12(6)731-739 

Wolff MS, Teitelbaum SL, Lioy PJ, Santella RM, Wang RY, Jones RL, Caldwell KL, Sjodin A, Turner WE, Li W, Georgopoulos P, Berkowitz GS. "Exposures Among 
Pregnant Women Near the World Trade Center Site on 1 1 September 2001". Environ Health Perspect. June 2005;1 13(6):739-48. 

Moline JM, Herbert R, Nguyen N. "Health Consequences of the September 11th World Trade Center Attacks: A Review. Cancer Investigation". Journal? 'May 2006; 
24(3): 294-301. 

Katz CL, Smith R, Silverton M, Holmes A, Bravo C, Jones K, Killiman M, Lopez N, Malkoff L, Marrone K, Neuman A, Stephens T, Tavarez W, Yarowsky A, Levin S, 
Herbert R. A "Mental Health Program for Ground Zero Rescue and Recovery Workers: Cases and Observations". Psychiatr Serv. September 2006; 57(9):1335- 
1338. 

Herbert R, Moline JM, Skloot G, Metzger K, Baron S, Luft B, Markowitz S, Udasin I, Harrison D, Stein D, Todd A, Enright P, Stellman JM, Landrigan PJ, Levin SM. 
"The World Trade Center Disaster and the Health of Workers: Five-Year Assessment of a Unique Medical Screening Program". Environ Health Perspect. December 
2006;114:1853-1858. 

Mendelson DS, Roggeveen M, Levin SM, Herbert R, de la Hoz RE. « Air Trapping Detected on End-Expiratory High-Resolution Computed Tomography in 
Symptomatic World Trade Center Rescue and Recovery Workers". J Occup Environ Med August 2007; 49(8): 840-845. 

de la Hoz RE, Shohet M, Chasan R, Bienenfeld L, Afilaka AA, Levin SM, Herbert R. "Occupational Toxicant Inhalation Injury: the World Trade Center (WTC) 
Experience". IntArch Occup Environ Health. February 2008;81 (4): 479-485. 

de la Hoz RE, Shohet M, Bienenfeld LA, Afilaka AA, Levin SM, Herbert R. "Vocal Cord Dysfunction in Former World Trade Center (WTC) Rescue and Recovery 
Workers and Volunteers. Am J Ind Med. March 2008; 51 (3): 1 61 -1 65. 

Moline JM, Herbert R, Levin S, Stein D, Luft B, Udasin IG, Landrigan PJ. "The WTC Medical Monitoring and Treatment Program: Comprehensive Health Care 
Response in Aftermath of Disaster". Mt. Sinai J Med. March-April 2008; 75(2): 67-75. 

Savitz, D, Oxman RT, Metzger KB, Wallenstein S, Stein D, Moline JM, Herbert R. "Epidemiologic Research on Man-Made Disasters: Strategies and Implications of 
Cohort Definition for the World Trade Center Worker and Volunteer Surveillance Program". Mt. Sinai J Med. March-April 2008; 75(2): 77-87. 
Szeinuk J, Padilla M, de la Hoz R. "Potential for Diffuse Parenchymal Lung Disease after Exposures at World Trade Center Disaster Site". Mt. Sinai J Med. March- 
April 2008, 75(2):101-107. 

Enright P, Skloot G, Herbert R. "Standardization of Spirometry in Assessment of Responders Following Man-Made Disasters: The World Trade Center Worker and 
Volunteer Medical Screening Program". Mt. Sinai J Med. March-April 2008; 75(2):109-114. 

Bills CB, Levy NA, Sharma V, Charney DS, Herbert R, Moline JM, Katz CL. "Mental Health of Workers and Volunteers Responding to Events of 9/1 1 : Review of Xh 
Literature". Mt. Sinai J Med. March-April 2008; 75(2):1 15-127. 

Landrigan PJ, Forman J, Galvez M, Newman B, Engel SM, Chemtob C. "Impact of September 11 World Trade Center Disaster on Children and Pregnant Women" 
Mt. Sinai J Med. March-April 2008; 75(2): 1 29-1 34. 
Reissman DB, Howard J. Responder Safety and Health: "Preparing for Future Disasters". Mt. Sinai J Med. March-April 2008; 75(2): 135-141. 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



List of Publications -to- date 



22. 

23. 

24. 

25. 

26. 

27. 

28. 

29. 

30. 

31. 

32. 

33. 
34. 



37. 
38. 



39. 
40. 



Other: 



Stellman J, Smith R, Katz CL, Sharma V, Charney D, Herbert R, Moline JM, Luft B, Markowitz S, Udasin I, Harrison D, Baron S, Landrigan PJ, Levin S, Southwick S. "Enduring 

Mental Health Morbidity and Social Function Impairment in World Trade Center Rescue, Recovery, and Cleanup Workers: The Psychological Dimension of an Environmental 

Health Disaster". Environ Health Perspect. September 2008; 1 16(9): 1248-1253. 

de la Hoz RE, Hill S, Chasan R, Bienenfeld LA, Afilaka AA, Wilk-Rivard E, Herbert R. Health Care and Social Issues of Immigrant Rescue and Recovery Workers at the World 

Trade Center Site. J Occup Environ Med December 2008; 50(1 2):1 329-1 334. 

de la Hoz RE, Christie J, Teamer JA, Bienenfeld LA, Afilaka AA, Crane M, Levin SM, Herbert R. Reflux Symptoms and Disorders and Pulmonary Disease in Former World 

Trade Center Rescue and Recovery Workers and Volunteers. J Occup Environ Med December 2008;50(12):1 351 -1354. 

Skloot G, Schechter CB, Herbert R, Moline JM, Levin SM, Crowley LE, Luft B, Udasin IG, Enright PL. "Longitudinal Assessment of Spirometry in the World Trade Center 

Medical Monitoring Program". Chest. February 2009; 135 (2):492-498 

Katz CL, Levin S, Herbert R, Munro S, Pandya A, Smith R. "Psychiatric Symptoms in Ground Zero Ironworkers in the Aftermath of 9/11: Prevalence and Predictors". 

Psychiatric Bulletin. February 2009; 33:49-52. 

Moline JM, Herbert R, Crowley L, Troy K, Hodgman E, Shukla G, Udasin I, Luft B, Wallenstein S, Landrigan P, Savitz DA. "Multiple Myeloma in World Trade Center 

Responders: A Case Series". J Occup Environ Med. August 2009; 51 (8):896-902. 

Bills CB, Dodson N, Stellman JM, Southwick S, Sharma V, Herbert R, Moline JM, Katz CL. "Stories Behind the Symptoms: a Qualitative Analysis of the Narratives of 9/1 1 

Rescue and Recovery Workers". Psychiatric Quarterly. (Published online July 2009 http://www.springerlink.com/content/t33j766259850175/fulltext.pdf) 

de la Hoz RE, Shohet MR, Wisnivesky JP, Bienenfeld LA, Afilaka AA, Herbert R. "Atopy and Upper and Lower Airway Disease Among Former World Trade Center Workers 

and Volunteers". J Occup Environ Med. September 2009; 51 :992-995. 

Enright P, Skloot G, Cox-Ganser J, Udasin IG, Herbert R. "Quality of Spirometry Tests Performed by 13,599 Participants of the World Trade Center Worker and Volunteer 

Medical Screening Program". J Respiratory Care. March 2010; 55(3), 303-309. 

Wallenstein S, Bodian C, Herbert R. "A Capture-Recapture Problem When Information Is Obtained from Two Qualitatively Different Sources". Communications in Statistics - 

Theory and Methods, September 201 0; 39(1 5), 2688-2700. 

de la Hoz RE, Aurora RN, Landsbergis P, Bienenfeld LA, Afilaka AA, Herbert R. "Snoring and Obstructive Sleep Apnea Among Former World Trade Center Rescue Workers 

and Volunteers". J Occup Environ Med. January 2010; 52:29-32. 

de la Hoz RE, Shohet MR, Cohen J. "Occupational Rhinosinusitis and Upper Airway Disease: the World Trade Center Experience". Curr Asthma Allergy Rep. March 2010; 

10(2), 77-83. 

Skloot G, Edwards NT, Enright P. "Four-year Calibration Stability of the EasyOne Portable Spirometer". J Respiratory Care. July 2010; 55(7), 873-877(5). 

Maoxin W, Gordon RE, Herbert R, Padilla M, Moline JM, Mendelson D, Litle V, Travis W, Gil J. "Lung Disease in World Trade Center Responders Exposed to Dust and 

Smoke-Carbon Nanotubes found in the Lungs of WTC Patients and Dust Samples". Environmental Health Perspectives. April 2010; 1 18(4), 499-504. 

Dalton PH, Opiekun RE, Gould M, McDermott R, Wilson T, Maute C, Ozdener MH, Zhao K, Emmett E, Lees PSJ, Herbert R, Moline J. "Chemosensory Loss: Functional 

Consequences of the World Trade Center Disaster". Envrion Health Perspectives, September 2010; 1 18(9), 1251-1256. 

de la Hoz RE. "Occupational Asthma and Lower Airway Disease Among World Trade Center Workers and Volunteers." Curr Allergy Asthma Rep April 2010; 10:287-294 

Crowley LE, Herbert R, Moline JM, Wallenstein S, Shukla G, Schechter C, Skloot GS, Udasin I, Luft BJ, Harrison D, Shapiro M, Wong K, Sacks HS, Landrigan PJ, Teirstein 

AS. "Sarcoid like" granulomatous pulmonary disease in World Trade Center disaster responders. American Journal of Industrial Medicine, March 201 1 ; 54: 1 75-1 84. 

Altman KW, Desai SC, Moline J, de la Hoz RE, Herbert R, Gannon PJ, Doty RL. "Odor identification ability and self-reported upper respiratory symptoms in workers at the 

post-9/1 1 World Trade Center site". Int Arch Occup Environ Health. February 201 1 ; 84:1 31 -1 37. 

de la Hoz RE. "Occupational lower airway disease in relation to World Trade Center inhalation exposure". Curr Opin Allergy Clin Immunol. April 201 1 ; 1 1 :97-1 02. 

WoskieSR, Kim, H, Freund A, Stevenson L, Park BY, Baron S, Herbert R, Siegel de Hernandez M, Teitelbaum S, de la Hoz RE, Wisnivesky JP, Landrigan PJ. "world Trade 

Center Disaster: Assessment of Responder Occupations, Work Locations, and Job Tasks." Am J Ind Med. August 201 1 . 54: 681 -695. 

Wisnivesky JP, Teitelbaum S, Todd A,Bofetta P, Crane M, Crowley LE, Dellenbaugh C, Harrison D, Herbert R, Kim H, Jeon Y, Kaplan J. Levin S, Luft B, Markowitz S, Moline 

JM, Pietrzak R, Shapiro M, Skloot GS, Southwick S, Stevenson L, Udasin I, Wallenstein S, Landrigan PJ . Persistence of Multiple Illnesses in September 1 1 Rescue Workers. 

Lancet September 201 1 . 378: 888-97. 

Katz CL, Smith R, Herbert R, Levin S, and Gross R. The World Trade Center worker/volunteer mental health screening program. In Neria Y, Gross R, Marshall R, and Susser 
E, eds. 9/1 1 : Public Mental Health in the Wake of a Terrorist Attack. Cambridge University Press, 2006. 



Future Scientific Projects 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Cancer among WTC Responders: Enhanced Surveillance, Exposure 
Assessment, and Cancer Specific Risks 




It is well established there is a latency between exposure and cancer 
development for most human carcinogens 

Prolonged follow-up is a necessity in this cohort 

Goals: 

□ Identify and validate all cancer cases in WTC responders 

□ Link exposure to cancer risk in WTC responders 



Identify risk of cancer among WTC responders 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Pulmonary Function Abnormalities, Diastolic Dysfunction and WTC 
Exposure - Implications for Diaqnosis and Treatment 



Goal: To determine the significance of the long-term effect of WTC 
particulate matter exposure on pulmonary function and cardiovascular 
health 

Participants will undergo: 

questionnaires 

□ pulmonary function testing 

□ echocardiogram 

□ sleep study 

laboratory tests (CBC, metabolic panel, FBS, lipid panel, hormone profile, 
inflammatory markers) 

Study will provide critical information regarding exposure and risk 
factors for development of cardiopulmonary disease. 

Resulting in improvements in monitoring, diagnosis and treatment 
protocols 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Trajectories of Psychological Risk and Resilience in WTC Responders 




Posttraumatic stress disorder (PTSD) and depression arising in response to this 
event are both highly prevalent (15%) and persistent, even several years after 9/1 1 

Goals: 

Examine the extent of resilience, recovery, and chronicity over a span of eight 
years among participants in the WTCHP 

Identify a set of modifiable risk factors that will inform personalized psychological 
intervention programs for this population 

Ultimately, our findings will help guide prevention efforts and preparedness planning 
for disaster responders 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Goals 




Active screening and monitoring of all WTC responders 

Identify and treat diseases in their early stages 

Report on changing trends of certain diseases overtime 

Continue surveillance of diseases with long latency 

Educate responders to seek medical care if they have developed 
any illness following the WTC disaster on 9/1 1 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Conclusion 




The WTC Health Program Clinical Centers of Excellence 
have medically screened over 30,000 WTC rescue and 
recovery workers and volunteers since it began in July 
2002 

The Clinical Centers of Excellence have provided 
treatment for over 15,000 WTC responders 

Program has been successful in establishing a vibrant 
occupational medicine consortium 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



Acknowledaements 



Dr. Philip Landrigan 
Dr. Michael Crane 
Dr. Robin Herbert 
Dr. Jacqueline Moline 
Dr. Steven Markowitz 
Dr. Iris Udasin 
Dr. Denise Harrison 
Dr. Benjamin Luft 

Matthew Cassidy 
Jean Weiner 
Carol Perret 
Lauri Boni 
Lin Luo 

Melodie Guerrera 
Gauri Shukla, MPH 

Dr. Jim Melius 

Lee Clarke 

Micki Siegel de Hernandez 

Dr. Jon Howard 
Dr. Dori Reissman 
Roy Fleming 




MOUNT SINAI 
SCHOOL OF 
MEDICINE 



. References 




Herbert R, Moline J, Skloot G, Metzger K, Baron S, Luft B, Markowitz S, Udasin I, HarrisonD, Stein D, Todd A, Enright P, Stellman JM, Landrigan PJ, 

Levin SM. 2006. The World Trade Center Disaster and the Health of Workers: Five-Year Assessment of a Unique Medical Screening Program. Environ 

Health Perspect 114:1853-1858. 

Savitz DA, Oxman RT, Metzger KB, Wallenstein S, Stein D, Moline J, Herbert R. 2008. Epidemiologic research on man-made disasters: Strategies and 

implications of cohortdefinition for World Trade Center worker and volunteer surveillance program. Mt Sinai J Med 75(2):77-87. 

Moline JM, Herbert R, Levin S, Stein D, Luft BJ, Udasin IG, Landrigan PJ. 2008 WTC medical monitoring and treatment program: comprehensive health 

care response in aftermath of disaster. Mt Sinai J Med 75(2):65-75 

The Mount Sinai Hospital. 201 1 . News Archive. New Study of "Sarcoid Like" Granulomatous Pulmonary Disease Finds Elevated Rates in WTC 

Responders. [Press Release]. Retrieved from: http://www.mountsinaihospital.org/about-us/news-archive/new-study-of-%E2%80%9Csarcoid- 

like%E2%80%9D-granulomatous-pulmonary-disease-finds-elevated-rates-in-wtc-responders 

The Mount Sinai Medical Center. 201 1 . World Trade Center Health Program. About the World Trade Center Health Program. Retrieved from: 

http://www.mountsinai.org/patient-care/service-areas/co 

world-trade-center-health-program 

Wisnivesky JP, Teitelbaum SL, Todd AC, Boffetta P, Crane M, Crowley L, de la Hoz RE, Dellenbaugh C, Harrison D, Herbert R, Kim H, Jeon Y, Kaplan 
J, Katz C, Levin S, Luft B, Markowitz S, Moline JM, Ozbay F, Pietrzak RH, Shapiro M, Sharma V, Skloot G, Southwick S, Stevenson LA, Udasin I, 
Wallenstein S, Landrigan PJ. 201 1 . Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study. Lancet 
378(9794) :888-897 




MOUNT SINAI 
SCHOOL OF 
MEDICINE