World Trade Center Exposure Research Articles

Long-term Cardiovascular Disease Risk Among Firefighters After the World Trade Center Disaster

Published studies examining the association between World Trade Center (WTC) exposure on and after September 11, 2001, and longer-term cardiovascular disease (CVD) outcomes have reported mixed findings. To assess whether WTC exposure was associated with elevated CVD risk in Fire Department of the City of New York (FDNY) firefighters. In this cohort study, the association between WTC exposure and the risk of CVD was assessed between September 11, 2001, and December 31, 2017, in FDNY male firefighters. Multivariable Cox regression analyses were used to estimate CVD risk in association with 2 measures of WTC exposure: arrival time to the WTC site and duration of work at the WTC site. Data analyses were conducted from May 1, 2018, to March 8, 2019. The primary CVD outcome included myocardial infarction, stroke, unstable angina, coronary artery surgery or angioplasty, or CVD death. The secondary outcome (all CVD) included all primary outcome events or any of the following: transient ischemic attack; stable angina, defined as either use of angina medication or cardiac catheterization without intervention; cardiomyopathy; and other CVD (aortic aneurysm, peripheral arterial vascular intervention, and carotid artery surgery). There were 489 primary outcome events among 9796 male firefighters (mean [SD] age on September 11, 2001, was 40.3 [7.4] years and 7210 individuals [73.6%] were never smokers). Age-adjusted incident rates of CVD were higher for firefighters with greater WTC exposure. The multivariable adjusted hazard ratio (HR) for the primary CVD outcome was 1.44 (95% CI, 1.09-1.90) for the earliest arrival group compared with those who arrived later. Similarly, those who worked at the WTC site for 6 or more months vs those who worked less time at the site were more likely to have a CVD event (HR, 1.30; 95% CI, 1.05-1.60). Well-established CVD risk factors, including hypertension (HR, 1.41; 95% CI, 1.10-1.80), hypercholesterolemia (HR, 1.56; 95% CI, 1.28-1.91), diabetes (HR, 1.99; 95% CI, 1.33-2.98), and smoking (current: HR, 2.13; 95% CI, 1.68-2.70; former: HR, 1.55; 95% CI, 1.23-1.95), were significantly associated with CVD in the multivariable models. Analyses with the all-CVD outcome were similar. The findings of the study suggest a significant association between greater WTC exposure and long-term CVD risk. The findings appear to reinforce the importance of long-term monitoring of the health of survivors of disasters.

Incidence of mild cognitive impairment in World Trade Center responders: Long-term consequences of re-experiencing the events on 9/11/2001

ObjectiveThis study examined whether World Trade Center (WTC) exposures and chronic posttraumatic stress disorder (PTSD) were associated with incidence of mild cognitive impairment (MCI) in a longitudinal analysis of a prospective cohort study of WTC responders. MethodsIncidence of MCI was assessed in a clinical sample of WTC responders (N = 1800) who were cognitively intact at baseline assessment. Crude incidence rates were calculated and compared to population estimates using standardized incidence ratios. Multivariable analyses used Cox proportional-hazards regression. ResultsResponders were 53.1 years old (SD = 7.9) at baseline. Among eligible cognitively intact responders, 255 (14.2%) developed MCI at follow-up. Incidence of MCI was higher than expected based on expectations from prior published research. Incidence was higher among those with increased PTSD symptom severity, and prolonged exposure was a risk factor in apolipoprotein-ε4 carriers. ConclusionsPTSD and prolonged WTC exposures were associated with increased incidence of MCI in WTC responders, results that may portend future high rates of dementia in WTC-exposed responders.

Shortened leukocyte telomere length is associated with reduced pulmonary function and greater subsequent decline in function in a sample of World Trade Center responders

The objective of this study was to examine whether shorter leukocyte telomere length (LTL) is associated with more rapid pulmonary function decline in a longitudinal study of World Trade Center (WTC) responders. WTC responders (N = 284) participating in a monitoring study underwent blood sampling and were followed prospectively for spirometric outcomes. A single blood sample was taken to measure LTL using southern blotting. Outcomes included percent-predicted one-second forced expiratory volume (FEV1%), forced vital capacity (FVC%), and the FEV1/FVC ratio. In a subset, percent-predicted diffusing capacity (DLCO%) was also measured. Longitudinal modeling examined prospectively collected information over five years since blood was banked was used to examine the rate of change in pulmonary functioning over time. Severity of WTC exposure was assessed. Shorter LTL was associated with lower FEV1% and FVC% at baseline. For example, 29.9% of those with LTL <6.5 kbps had FEV1% <80% whereas only 12.4% of those with LTL ≥6.5 had FEV1% <80% (RR = 2.53, 95%CI = [1.70–3.76]). Lower DLCO% was also significantly associated with shorter LTL. Longitudinal models identified a prospective association between shorter LTL and greater yearly rates of decline in FEV1% (0.46%/year, 95%CI = [0.05–0.87]) and in the FEV1/FVC ratio (0.19%/year, 95%CI = [0.03–0.36]). There were no associations between severity of exposure and either LTL or pulmonary function. Longitudinal analyses revealed that shorter LTL, but not severity of WTC exposures, was associated with poorer pulmonary functioning and with greater subsequent decline in pulmonary functioning over time. These findings are consistent with the idea that shortened LTL may act as a biomarker for enhanced pulmonary vulnerability in the face of acute severe toxic inhalation exposures.

Post-9/11 Peripheral Neuropathy Symptoms among World Trade Center-Exposed Firefighters and Emergency Medical Service Workers.

Peripheral neuropathy can result from numerous conditions including metabolic disorders, inflammatory disease, or exposure to environmental or biological toxins. We analyzed questionnaire data from 9239 Fire Department of the City of New York (FDNY) World Trade Center (WTC)-exposed firefighters and emergency medical service workers (EMS) to evaluate the association between work at the WTC site and subsequent peripheral neuropathy symptoms using the validated Diabetic Neuropathy Symptom (DNS) score. We grouped the population into an “Indicated” group with conditions known to be associated with paresthesia (N = 2059) and a “Non-Indicated” group without conditions known to be associated (N = 7180). The level of WTC exposure was categorized by time of arrival to the WTC. Overall, 25% of workers aged 40 and older reported peripheral neuropathy symptoms: 30.6% in the Indicated and 23.8% in the Non-Indicated groups, respectively. Multivariable logistic models performed on the Non-Indicated group, and on the Non-Indicated in comparison with non-WTC exposed National Health and Nutrition Examination Survey (NHANES), found that the highest level of WTC-exposure was significantly associated with DNS positive outcomes, after controlling for potential confounders. In conclusion, this study suggests that symptoms of peripheral neuropathy and paresthesias are common and are associated with WTC-exposure intensity.

Genetic Variants Associated with FDNY WTC-Related Sarcoidosis.

Sarcoidosis is a systemic granulomatous disease of unknown etiology. It may develop in response to an exposure or inflammatory trigger in the background of a genetically primed abnormal immune response. Thus, genetic studies are potentially important to our understanding of the pathogenesis of sarcoidosis. We developed a case-control study which explored the genetic variations between firefighters in the Fire Department of the City of New York (FDNY) with World Trade Center (WTC)-related sarcoidosis and those with WTC exposure, but without sarcoidosis. The loci of fifty-one candidate genes related to granuloma formation, inflammation, immune response, and/or sarcoidosis were sequenced at high density in enhancer/promoter, exonic, and 5’ untranslated regions. Seventeen allele variants of human leukocyte antigen (HLA) and non-HLA genes were found to be associated with sarcoidosis, and all were within chromosomes 1 and 6. Our results also suggest an association between extrathoracic involvement and allele variants of HLA and non-HLA genes found not only on chromosomes 1 and 6, but also on chromosomes 16 and 17. We found similarities between genetic variants with WTC-related sarcoidosis and those reported previously in sporadic sarcoidosis cases within the general population. In addition, we identified several allele variants never previously reported in association with sarcoidosis. If confirmed in larger studies with known environmental exposures, these novel findings may provide insight into the gene-environment interactions key to the development of sarcoidosis.

Abnormalities on Chest Computed Tomography and Lung Function Following an Intense Dust Exposure: A 17-Year Longitudinal Study.

Fire Department of the City of New York (FDNY) firefighters experienced intense dust exposure working at the World Trade Center (WTC) site on and after 11/9/2001 (9/11). We hypothesized that high-intensity WTC exposure caused abnormalities found on chest computed tomography (CT). Between 11/9/2001–10/9/2018, 4277 firefighters underwent a clinically-indicated chest CT. Spirometric measurements and symptoms were recorded during routine medical examinations. High-intensity exposure, defined as initial arrival at the WTC on the morning of 9/11, increased the risk of bronchial wall thickening, emphysema, and air trapping. Early post-9/11 symptoms of wheeze and shortness of breath were associated with bronchial wall thickening, emphysema, and air trapping. The risk of accelerated forced expiratory volume at one second (FEV1) decline (>64 mL/year decline) increased with bronchial wall thickening and emphysema, but decreased with air trapping. The risk of airflow obstruction also increased with bronchial wall thickening and emphysema but decreased with air trapping. In a previously healthy occupational cohort, high-intensity WTC exposure increased the risk for CT abnormalities. Bronchial wall thickening and emphysema were associated with respiratory symptoms, accelerated FEV1 decline, and airflow obstruction. Air trapping was associated with respiratory symptoms, although lung function was preserved. Physiologic differences between CT abnormalities suggest that distinct types of airway injury may result from a common exposure.

Metabolic Syndrome Biomarkers of World Trade Center Airway Hyperreactivity: A 16-Year Prospective Cohort Study.

Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N = 7486 World Trade Center (WTC)-exposed male firefighters from 11 September 2001 (9/11) until 1 August 2017 and investigated N = 539 with newly developed AHR for clinical biomarkers of MetSyn and compared them to the non-AHR group. Male firefighters with normal lung function and no AHR pre-9/11 who had blood drawn from 9 September 2001–24 July 2002 were assessed. World Trade Center-Airway Hyperreactivity (WTC-AHR) was defined as either a positive bronchodilator response (BDR) or methacholine challenge test (MCT). The electronic medical record (EMR) was queried for their MetSyn characteristics (lipid profile, body mass index (BMI), glucose), and routine clinical biomarkers (such as complete blood counts). We modeled the association of MetSyn characteristics at the first post-9/11 exam with AHR. Those with AHR were significantly more likely to be older, have higher BMIs, have high intensity exposure, and have MetSyn. Smoking history was not associated with WTC-AHR. Those present on the morning of 9/11 had 224% increased risk of developing AHR, and those who arrived in the afternoon of 9/11 had a 75.9% increased risk. Having ≥3 MetSyn parameters increased the risk of WTC-AHR by 65.4%. Co-existing MetSyn and high WTC exposure are predictive of future AHR and suggest that systemic inflammation may be a contributor.

Time to Onset of Paresthesia Among Community Members Exposed to the World Trade Center Disaster.

We examined whether time to onset of paresthesia was associated with indicators of severity of World Trade Center (WTC) exposure. We analyzed data from 3411 patients from the Bellevue Hospital—WTC Environmental Health Center. Paresthesia was defined as present if the symptom occurred in the lower extremities with frequency “often” or “almost continuous.” We plotted hazard functions and used the log-rank test to compare time to onset of paresthesia between different exposure groups. We also used Cox regression analysis to examine risk factors for time-to-paresthesia after 9/11/2001 and calculate hazard ratios adjusted for potential confounders. We found significantly elevated hazard ratios for paresthesia for (a) working in a job that required cleaning of WTC dust in the workplace; and (b) being heavily exposed to WTC dust on September 11, 2001, after adjusting for age, race/ethnicity, depression, anxiety, post-traumatic stress disorder, and body mass index. These observational data are consistent with the hypothesis that exposure to WTC dust or some other aspect of cleaning WTC dust in the workplace, is associated with neuropathy and paresthesia. Further neurological evaluations of this and other WTC-exposed populations is warranted.

Posttraumatic stress disorder and total amyloid burden and amyloid-β 42/40 ratios in plasma: Results from a pilot study of World Trade Center responders

IntroductionChronic posttraumatic stress disorder (PTSD) is associated with poor memory and increased burden of various degenerative cerebral neuropathologies. The goal of this pilot study was to determine whether PTSD was associated with changes in plasma-based neuropathological biomarkers of neurodegeneration among World Trade Center (WTC) responders. MethodsThirty-four WTC responders had blood drawn and flash-frozen within 15 minutes of retrieval. PTSD symptoms were assessed at that time. Age, sex, and WTC exposure duration were obtained from medical records. Plasma was assayed in duplicate using an ultra-sensitive single-molecule enzyme-linked immunosorbent assay to examine the distribution of amyloid-β (Aβ) 42/40 ratios, total Aβ, total tau, and neurofilament light (NfL). The comparison group was drawn from a bank of healthy controls collected and assayed at the same facility. ResultsThe average age of WTC responders at blood draw was 53 years. Half were PTSD positive (PTSD+) as indicated by symptom severity. WTC responders had lower Aβ42/Aβ40 ratios but higher total tau and NfL levels in the plasma than healthy controls. PTSD+ status was associated with lower plasma Aβ load and higher Aβ42/Aβ40 ratios. DiscussionFindings suggest that PTSD may be associated with alterations in plasma markers related to Aβ, tau, and NfL, highlighting the potential association between PTSD status and neurodegenerative neuropathology in WTC responders.

Excess HPV-related head and neck cancer in the world trade center health program general responder cohort.

The World Trade Center (WTC) attacks exposed rescue and recovery workers to a complex mix of toxicants, including carcinogens. our study compared site-specific cancer incidence of head and neck cancers (HNC) from 2003 through 2012 among 33,809 consented WTC General Responder Cohort (GRC) members to the New Jersey State Cancer Registry, using standardized incidence ratios (SIRs). HNC grouped using SEER ICD-O-3 codes into HPV-related (oropharyngeal) and non-related (other oral-nasal; laryngeal) tumors based on anatomical site. For the 73 GRC members identified with HNC, proportional hazard regression assessed the relationship between WTC exposure and other socio-demographic characteristics. An overall excess of HNC was not observed (SIR = 1.00, 95% CI: 0.78, 1.25) but excess cancer was seen in the latest observation period (2009-2012: SIR = 1.4; 95% CI: 1.01, 1.89). A similar temporal pattern was seen for HPV-related oropharyngeal cancer and laryngeal cancer, but not for non-HPV-related sites (oral-nasal cancer). HNC was significantly associated with increasing age (8% per year, 95% CI: 5%, 12%), non-Hispanic white ethnic group-ethnicity (hazard ratio (HR) = 3.51, 95 CI: 1.49, 8.27); there was a borderline association with the 9/11 occupation of military/protective services vs. others (HR = 1.83 95% CI: 0.99, 3.38; p = 0.0504). Caution is needed in interpreting these results given the small number of cases, potential for surveillance bias, and long latency for most cancers. Our findings highlight the need to examine the potentially carcinogenic effects of WTC exposure in the context of other strong risk factors, and the need for continued medical monitoring of WTC responders.

Past Experiences of Getting Bullied and Assaulted and Posttraumatic Stress Disorder (PTSD) after a Severe Traumatic Event in Adulthood: A Study of World Trade Center (WTC) Responders

ABSTRACTAlthough experiencing bullying and other forms of assault is associated with adverse physical, emotional, and psychological consequences, the long-term consequences, especially in the aftermath of a severe trauma in adulthood, is not known. This study examined the relationship between history of being bullied and/or assaulted and posttraumatic stress disorder (PTSD) symptoms among responders to the World Trade Center (WTC) disaster. During 2015–2016, a modified life events checklist was administered to responders at Stony Brook WTC Health Program. WTC-related PTSD symptoms were assessed by PTSD checklist (PCL). Longitudinal mixed models examined associations between bullying, other forms of assault, and severity and chronicity of PTSD symptoms. Approximately, 13% of 920 responders had probable WTC-PTSD (PCL≥44). Being bullied in childhood was associated with increased odds of WTC-PTSD (adjusted odds ratio [aOR] = 7.34; 95% confidence interval [CI] = 2.12–25.34), adjusted for demographics, other stressors, and WTC exposures. PTSD odds decreased over time among those not bullied (aOR 0.82; 95% CI: 0.73–0.92), but not among victims. Experiencing physical, sexual, or verbal assaults during adulthood also had a significant association with WTC-PTSD (aOR 4.64; 95% CI: 1.98–10.92). Findings suggest being bullied in childhood and/or assaulted in adulthood can increase PTSD risk and progression after mass trauma.

Characterizing Mental Health Treatment Utilization among Individuals Exposed to the 2001 World Trade Center Terrorist Attacks 14⁻15 Years Post-Disaster.

Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, none have data more than two years post-disaster. We used data from 35,629 enrollees of the WTC Health Registry, a longitudinal cohort study of those exposed to the WTC attacks, to examine predictors of counseling after 9/11, the types of practitioners seen, and the perceived helpfulness of therapy up to 15 years post-disaster. Among enrollees, 37.7% reported receiving counseling at some time after 9/11. Predictors of seeking counseling included race/ethnicity, age at 9/11, education level, exposure to the WTC attacks, other traumatic experiences, mental health symptomology, and pre-9/11 counseling. Whites and Hispanics, those who were children on 9/11, and those with high levels of exposure to the WTC attacks sought counseling soonest after 9/11. Among those who sought counseling, Blacks, Asians, and those with lower education and income were less likely to see mental health specialists and more likely to see general practitioners or religious advisors. Finally, among those who sought recent counseling, women, Blacks, those aged ≥65 years, and those with very high WTC exposures were more likely to rate their recent counseling as very helpful. This study used data up to 15 years post-disaster to document mental health treatment utilization patterns, trends, and disparities that have implications for future preparedness plans and needs assessments.

Cord blood perfluoroalkyl substances in mothers exposed to the World Trade Center disaster during pregnancy

Perfluoroalkyl substances (PFAS) may have been released during the collapse of the World Trade Center (WTC) on 9/11. Evidence suggests PFAS can cross the placental barrier in humans and cause harm to the developing fetus; however, no studies have measured PFAS in mothers exposed to the WTC disaster during pregnancy. We measured PFAS in maternal plasma (n = 48) or cord blood (n = 231) from pregnant women in the Columbia University WTC birth cohort, enrolled between December 13, 2001 and June 26, 2002 at one of three hospitals located near the WTC site. In order to maximize sample size, we used a linear regression to transform the 48 maternal plasma samples to cord blood equivalents in our study; cord blood and transformed maternal plasma-to-cord blood samples were then analyzed together. We evaluated the association between WTC exposure and PFAS concentrations using three exposure variables: 1) living/working within two miles of WTC; 2) living within two miles of WTC regardless of work location; and 3) working but not living within two miles of WTC. Exposure was compared with those not living/working within two miles of WTC (reference group). Living/working within two miles of WTC was associated with 13% higher perfluorooctanoic acid (PFOA) concentrations compared with the reference group [GMR (95% CI): 1.13 (1.01, 1.27)]. The association was stronger when comparing only those who lived within two miles of WTC to the reference group [GMR (95% CI): 1.17 (1.03, 1.33)], regardless of work location. Our results provide evidence that exposure to the WTC disaster during pregnancy resulted in increases in PFAS concentrations, specifically PFOA. This work identifies a potentially vulnerable and overlooked population, children exposed to the WTC disaster in utero, and highlights the importance of future longitudinal studies in this cohort to investigate later life effects resulting from these early life exposures.

Risk factors for post-9/11 chronic rhinosinusitis in Fire Department of the City of New York workers

ObjectivesChronic rhinosinusitis (CRS) has high socioeconomic burden but underexplored risk factors. The collapse of the World Trade Center (WTC) towers on 11 September 2001 (9/11) caused dust and smoke exposure,...

ISOLATED DISTAL AIRWAY DYSFUNCTION AS A MECHANISM OF DYSPNEA IN A PATIENT WITH NORMAL SPIROMETRY

SESSION TITLE: Allergy and Airway SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/07/2018 10:45 AM - 11:45 AM INTRODUCTION: Abnormalities in the small airways in the lung may not be reflected in spirometry which is essentially an assessment of large airways. The small airways are the so-called "silent zone of the lung" but represent 75% of the airways because of multiple branching. Oscillometry (IOS) is a technique to assess airways more distal. We present a patient who had severe dyspnea with normal spirometry but with significant small airway abnormality induced by exercise (forced oscillometry technique). CASE PRESENTATION: This is a 70 year old male (BMI 34.2kg/m2) with a history of World Trade Center (WTC) exposure who presented with unexplained dyspnea at rest as well as with exertion. He reported that symptoms began after 9/11 and had progressively worsened. He was being treated with intermittent bronchodilators and inhaled steroids but was not compliant with therapy. Cardiac workup on admission revealed no acute cardiac or respiratory disease. Pulmonary function tests were performed on the day of admission. Spirometry revealed normal lung volumes and normal airflow (FEV1/FVC = 77%). Resistance assessed by oscillometry was abnormal (R5 7.09 cm H20/L/sec), suggesting small airway abnormality. Pulmonary function was repeated on the sixth day of hospitalization following treatment with standing bronchodilators. Oscillometry had nearly normalized at resting conditions (R5 5.29 cm H20/L/sec) and patient reported relief of dyspnea at rest. Exercising the patient (“fast walk”) brought on dyspnea and increased abnormality on oscillometry (R5 9.53 cm H20/L/sec). His symptoms were attributed to small airway abnormality with possible etiologies including WTC exposure, central circulatory congestion, and/or obesity with mass loading of thoracic cage. DISCUSSION: Findings of abnormal oscillometry in this patient are compatible with exercise-induced small airway abnormality despite relatively normal large airway function based on spirometry. This has been previously documented by Lee who found an increase in peripheral airways resistance with exercise despite normal large airway function in child asthmatics. Without assessment of distal airway function, etiology of this patient’s dyspnea would not have been diagnosed. CONCLUSIONS: In the evaluation of unexplained dyspnea, oscillometry can provide insight when spirometry is normal. When symptoms are exertional, testing during exertion can elicit abnormalities not demonstrable at rest. Testing the patient while symptomatic, such as with exercise, can uncover pathophysiology since isolated distal airway dysfunction can be a source of dyspnea both at rest and on exertion. Reference #1: Lee, J.H., Lee, Y.W., Shin, Y.S., Jung, Y.H., Hong, C.S., and Park, J.W. Exercise-induced airway obstruction in young asthmatics measured by impulse oscillometry. J Investig Allergol Clin Immunol. 2010; 20: 575–581. Reference #2: Oppenheimer, B. W., Goldring, R. M., Herberg, M. E., Hofer, I. S., Reyfman, P. A., Liautaud, S., . . . Berger, K. I. (2007). Distal Airway Function in Symptomatic Subjects With Normal Spirometry Following World Trade Center Dust Exposure. Chest, 132(4), 1275-1282. https://doi.org/10.1378/chest.07-0913. Reference #3: Soghier, I; Smith, D; Berger, KI; Goldring, RM; Oppenheimer, BW. "Dysfunction Of The Distal Airway And Alveolar Capillary Membrane (distal Lung Unit) During Steady State Exercise". American journal of respiratory & critical care medicine. 2016; 193: 2414752. DISCLOSURES: No relevant relationships by Kenneth Berger, source=Web Response No relevant relationships by Roberta Goldring, source=Web Response No relevant relationships by Sheeja Thomas, source=Web Response

Head and Neck Cancer in World Trade Center Responders: A Case Series.

The aim of this study was to report on cases of head and neck cancer (HNC) among World Trade Center (WTC) responders participating in the WTC Health Program and seen at Rutgers WTC Center of Clinical Excellence. Medical records were abstracted by two clinical reviewers and discrepancies resolved. Cases were defined as WTC responders diagnosed with HNC between December 9, 2005, and December 31, 2016. Sixteen HNC patients met the case definition, most (13) arrived at the WTC location on 9/11 or within the following 2 days, and half worked in law enforcement during the 9/1 response. An association between HNC and WTC exposure is biologically plausible and should be further investigated. Research to enumerate the risk factor profile for these cancers may contribute to understanding mechanisms by which WTC exposure can contribute to carcinogenesis and to prevention and early detection strategies.

Respiratory Health and Lung Function in Children Exposed to the World Trade Center Disaster

To compare lung function in a representative sample of World Trade Center (WTC)-exposed children with matched comparisons, and examine relationships with reported exposures. Study population consisted of 402 participants. Oscillometry, spirometry, and plethysmography were performed on WTC Health Registry (WTCHR) respondents who were ≤8 years of age on September 11, 2001 (n = 180) and a sociodemographically matched group of New York City residents (n = 222). We compared lung function by study arm (WTCHR and comparison group) as well as dust cloud (acute); home dust (subchronic); and other traumatic, nondust exposures. In multivariable models, post-9/11 risk of incident asthma was higher in the WTCHR participants than in the comparison group (OR 1.109, 95% CI 1.021, 1.206; P = .015). Comparing by exposure rather than by group, dust cloud (OR 1.223, 95% CI 1.095, 1.365; P < .001) and home dust (OR 1.123, 95% CI 1.029, 1.226; P = .009) exposures were also associated with a greater risk of incidence of post-9/11 asthma. No differences were identified for lung function measures. Although we cannot exclude an alternative explanation to the null findings, these results may provide some measure of reassurance to exposed children and their families regarding long-term consequences. Further study with bronchodilation and/or methacholine challenge may be needed to identify and further evaluate effects of WTC exposure. Biomarker studies may also be more informative in delineating exposure-outcome relationships. ClinicalTrials.gov: NCT02068183.

Predictors of Asthma/COPD Overlap in FDNY Firefighters With World Trade Center Dust Exposure: A Longitudinal Study

Previously healthy firefighters with World Trade Center (WTC) dust exposure developed airway disease. Risk factors for irritant-associated asthma/COPD overlap are poorly defined. This study included 2,137 WTC-exposed firefighters who underwent a clinically indicated bronchodilator pulmonary function test (BD-PFT) between 9/11/2001 and 9/10/2017. A post-BD FEV1 increase of > 12%and 200mL from baseline defined asthma, and a post-BD FEV1/FVC ratio< 0.7 identified COPD cases. Participants who met both criteria had asthma/COPD overlap. Eosinophil levels were measured on screening blood tests performed shortly after 9/11/2001 and prior to BD-PFT; a subgroup of participants also had serum IgE and 21 cytokines measured (n= 215). Marginal Cox regression models for multiple events assessed the associations of eosinophil levels or serum biomarkers with subsequent diagnosis, with age, race, smoking, WTC exposure, first post-9/11 FEV1/FVC ratio, and BMI included as covariates. BD-PFT diagnosed asthma/COPD overlap in 99 subjects (4.6%), isolated-asthma in 202 (9.5%), and isolated-COPD in 215 (10.1%). Eosinophil concentration≥ 300 cells/μL was associated with increased risk of asthma/COPD overlap (hazard ratio [HR], 1.85; 95%CI, 1.16-2.95) but not with isolated-asthma or isolated-COPD. Serum IL-4 also predicted asthma/COPD overlap (HR, 1.51 per doubling of cytokine concentration; 95%CI, 1.17-1.95). Greater IL-21 concentration was associated with both isolated-asthma and isolated-COPD (HRs of 1.73 [95%CI, 1.27-2.35] and 2.06 [95%CI, 1.31-3.23], respectively). In WTC-exposed firefighters, elevated blood eosinophil and IL-4 levels are associated with subsequent asthma/COPD overlap. Disease-specific T-helper cell type 2 biomarkers present years before diagnosis suggest patient-intrinsic predisposition to irritant-associated asthma/COPD overlap.

Prostate cancer characteristics in the World Trade Center cohort, 2002-2013.

An increased incidence of prostate cancer was reported in three cohorts of World Trade Center (WTC) respondents. It is uncertain whether this increase is because of WTC-related exposures or enhanced surveillance. Prostate cancer cases (2002-2013) were obtained from the WTC Health Program. Age, race, and Gleason score distribution were compared with New York State Cancer Registry cases from the same time period. Multivariate models were adjusted for age and race. Analyses of clinical characteristics of prostate cancer cases within the cohort were also carried out, adjusting for age, race, and WTC exposure categories. WTC respondents had a prostate cancer age-standardized rate ratio of 1.65 [95% confidence interval (CI): 1.37-1.93] compared with New York State; age-specific ratios were highest for ages 30-49 (2.28; 95% CI: 1.51-3.43), 70-74 (2.05; 95% CI: 1.03-4.10), and 80-84 years (5.65; 95% CI: 1.41-22.58). High WTC exposure was associated with advanced clinical stage (5.58; 95% CI: 1.05-29.76; Ptrend=0.03). WTC respondents continue to have a higher prostate cancer rate compared with New York State as a whole. Respondents with a higher WTC exposure level may have had more advanced clinical stage of prostate cancer.

Asthma among World Trade Center First Responders: A Qualitative Synthesis and Bias Assessment.

The World Trade Center (WTC) disaster exposed the responders to several hazards. Three cohorts i.e., the Fire Department of New York (FDNY), the General Responder Cohort (GRC), and the WTC Health Registry (WTCHR) surveyed the exposed responder population. We searched Pubmed and Web of Science for literature on a well-published association between the WTC exposures and asthma, focusing on new-onset self-reported physician-diagnosed asthma. The resulting five articles were qualitatively assessed for potential biases. These papers were independently reviewed by the co-authors, and conclusions were derived after discussions. While, the cohorts had well-defined eligibility criteria, they lacked information about the entire exposed population. We conclude that selection and surveillance biases may have occurred in the GRC and WTCHR cohorts, but were likely to have been minimal in the FDNY cohort. Health care benefits available to responders may have increased the reporting of both exposure and outcome in the former, and decreased outcome reporting in the FDNY cohort. Irrespective of the biases, the studies showed similar findings, confirming the association between WTC exposure and self-reported physician-diagnosed asthma among responders. This suggests that health data gathered under great duress and for purposes other than epidemiology can yield sound conclusions. Potential biases can, however, be minimized by having validated survey instruments and worker registries in place before events occur.