Published Research/Publications

Published Research

Jacobson MH, Norman C, Nguyen A, Brackbill R. Longitudinal Determinants of Depression Among World Trade Center Health Registry Enrollees, 14-15 Years After the 9/11 Attacks. Journal of Affective Disorders. 2018.

This was a study of the longitudinal predictors of depression among a cohort exposed to 9/11 attacks. We found that depression more common among those with history of PTSD (56.2%) vs. without (5.6%). Low income, unemployment, and low social support increased the risk of depression among those with and without a history of PTSD. In general, the risk factors for depression were similar for those with and without a history of PTSD.

Jordan HT, Stein CR, Li J, Cone JE, et al. Mortality Among Rescue and Recovery Workers and Community Members Exposed to the September 11, 2001 World Trade Center Terrorist Attacks, 2003-2014. Environmental Research, 2018.

Have more deaths occurred among persons directly exposed to the 9/11 disaster than expected, based on comparison to the general New York City population? The WTC Health Registry identified the number and causes of death among Registry enrollees between the years of 2003-2014 via linkage to the National Death Index. We compared this number to the expected number of deaths based on mortality rates in the general NYC population. Overall, mortality among WTC Health Registry enrollees was not elevated. In fact, fewer deaths occurred than would be expected, based on comparison to the general NYC population. Registry enrollees had fewer cardiovascular and respiratory deaths than expected based on NYC reference rates. However, there were more deaths due to suicide among rescue-recovery workers than expected; these deaths mostly occurred among workers who did not perform rescue and recovery work in their usual, pre-9/11 work. There were also more deaths than expected due to non-Hodgkin’s lymphoma among community members. Even though the number of deaths overall was not elevated among Registry enrollees, there appears to have been an increased risk of death associated with higher levels of 9/11-related exposures. The Registry will continue to follow the numbers and causes of death among enrollees.

Lisa M. Gargano, PhD, MPH, Sean Locke, MPH, Hannah T. Jordan, MD, MPH, Robert M. Brackbill, PhD, MPH. Lower Respiratory Symptoms Associated with Environmental and Reconstruction Exposures after Hurricane Sandy.

The flooding after Hurricane Sandy (Sandy) resulted in conditions that could potentially lead to an increased risk of lower respiratory symptoms (LRS). This study sought to determine the relationship between Sandy-related exposures and post-Sandy LRS in a population with prior exposure to the World Trade Center disaster. The Sandy-related inhalational exposures examined were: 1) reconstruction exposure; 2) mold or damp environment exposure; and 3) other respiratory irritants exposure. Over one-third of participants reported post-Sandy LRS. Enrollees reporting any of the exposures were twice as likely to have post-Sandy LRS. There was a dose-response relationship between the number of Sandy-related exposures reported and post-Sandy LRS. This study shows that post-hurricane clean-up and reconstruction exposures can increase the risk for LRS. Public health interventions should emphasize the importance of safe remediation practices and recommend use of personal protective equipment.

Cheryl Stein, PhD, David J. Lee, PhD, Gregory A. Flamme, PhD, and James E. Cone, MD, MPH. Persistent Post-9/11 Hearing Problems Among World Trade Center Health Registry Rescue and Recovery Workers, 2001 to 2007. JOEM 2017.

Hearing loss is a concern among World Trade Center Health Registry (WTCHR) enrollees. A previous study of enrollees who were WTC Tower survivors found that exposure to the cloud of dust and debris generated by the collapse and fires in the WTC Towers and surrounding buildings was associated with reported hearing problems. More recently enrollees have contacted the Registry to discuss concerns about hearing loss. Possible WTC-related causes for hearing loss include ruptured ear drums, head trauma from injuries, toxic exposures in smoke, dust and debris, or noise exposure. Our recently published study found that among those rescue and recovery workers without pre-9/11 hearing problems, 4.4% reported persistent hearing problems in 2006-2007. Men reported more hearing problems than women, and on average, those with hearing problems were older. The prevalence of hearing problems increased with increased numbers of WTC-related environmental hazards. Workers who reported being unable to hear in the dust cloud had over 2 times the odds of reporting hearing problems, compared to workers not in the dust cloud. This study has led the Registry to partner with the Fire Department of the City of New York in a study of hearing function before and after 9/11/01 among firefighters and Emergency Medical Service workers. Future disaster follow-up should include surveillance evaluation of hearing loss among responders.

Hospitalizations for Asthma among Adults Exposed to the September 11, 2001 World Trade Center Terrorist Attack

Miller-Archie SA, Jordan HT, Alper H, et al. J Asthma. 2017;6:0.

Exposure to the World Trade Center attacks on September 11, 2001 has been linked with new and worsening asthma. In addition, conditions that commonly occur with and that can exacerbate asthma, namely gastroesophageal reflux symptoms (GERS) and posttraumatic stress disorder (PTSD), have also been associated with the 9/11 attacks. However, little is known about hospitalizations for asthma within this population. The World Trade Center Health Registry matched its records with New York State hospitalization records to identify enrollees who had been hospitalized for asthma between September 11, 2001 and December 31, 2010. Of the 11,471 enrollees with asthma, 406 (3.5%) had been hospitalized at least once for asthma, for a total of 721 hospitalizations. Among enrollees who were first diagnosed with asthma before 9/11, those with PTSD or GERS had twice the rate of asthma hospitalizations, after accounting for age, sex, education, smoking, and 9/11 exposure. Enrollees who were black or Latino and those with less than a college degree also had an increased rate of hospitalization. Medical management of comorbid physical and mental health conditions may play an important role in preventing hospitalizations for asthma.

Injury, Intense Dust Exposure, and Chronic Disease among Survivors of the World Trade Center Terrorist Attacks of September 11, 2001

Alper HE, Yu S, Stellman SD, Brackbill RM. Inj Epidemiol. 2017;4(1):17.

Many people exposed to the September 11, 2001 terrorist attacks developed chronic diseases years later, but little is known about the association between chronic disease and exposure to the 9/11 attacks (e.g. injury, dust cloud), among those exposed exclusively or mainly on the day of the attacks. This study investigated the association between heart disease and injury, and between asthma/other lung diseases and dust cloud exposure, among those whose exposure occurred on 9/11 and not afterwards. Heart disease exhibited a substantial and significant association with number of injury types sustained on 9/11, while asthma and other lung diseases were significantly associated with intense dust cloud exposure on 9/11. These results suggest the need for continued monitoring of 9/11 exposed persons by medical providers.”

Parent Physical and Mental Health Comorbidity and Adolescent Behavior. Int J Emerg Ment Health

Gargano L, Locke S, Brackbill RM. 2017;19(2):358-65.

Previous Registry findings showed that exposure to the 9/11-disaster was associated with behavior problems in adolescents 6-7 years after the event. In addition, 9/11-related post-traumatic stress disorder (PTSD) among parents has been associated with behavior problems in their adolescent. This study examined behavior problems in adolescents 10-11 years after 9/11. Even 10-11 years later, adolescents with moderate/severe 9/11-exposure were more likely to have behavior problems. Adolescents whose parent had comorbid 9/11-related PTSD and at least one other chronic health condition were more likely to have behavior problems then adolescents whose parents had 9/11-related PTSD only or chronic health condition only. Parents who reported 14 or more poor mental health days were more likely to have an adolescent with behavior problems.

The Effectiveness of a Monetary Incentive Offer on Survey Response Rates and Response Completeness in a Longitudinal Study

Yu S, Alper HE, Nguyen AM, et al. BMC Med Res Methodol. 2017;17(1):77.

Using the World Trade Center Health Registry’s Wave 4 survey data, this study evaluated the effectiveness of a monetary incentive in improving the response rate five months after survey launch, and assessed whether or not response completeness was compromised due to incentive use. We found that the likelihood of returning a survey increased by 30% for those who received an incentive offer (AOR=1.3, 95% CI: 1.1, 1.4), and the incentive increased the number of returned surveys by 18%. Moreover, our results did not reveal any significant differences on response completeness between those who received an incentive offer and those who did not. This study showed the value of offering a monetary incentive as an additional refusal conversion strategy.

Risk Factors for Persistence of Lower Respiratory Symptoms among Community Members Exposed to The 2001 World Trade Center Terrorist Attacks

Jordan H, Friedman SM, Reibman J, et al. Occup Environ Med. 2017;74(6):449-55.

Many lower Manhattan community members who were exposed to dust and fumes during the 9/11/2001 World Trade Center attacks have persistent lower respiratory symptoms, but little is known about underlying pulmonary function or risk factors for symptom persistence. We conducted in-depth interviews and tests of pulmonary function among 545 community members enrolled in the WTC Health Registry in 2008-2010, and a follow-up exam in 2013-2014. Most participants with persistent post-9/11-onset lower respiratory symptoms in 2013-2014 had evidence of peripheral airway dysfunction, despite having normal spirometry results. Peripheral airway dysfunction and 9/11-related posttraumatic stress disorder were each independently associated with the persistence of lower respiratory symptoms 12-13 years after the attacks. These findings underscore the importance of coordinating mental and physical health care for survivors of complex environmental disasters, and suggest that peripheral lung function assessment should be included in the evaluation of lower respiratory symptoms after such exposures.

Psychological Distress in Parents and School-Functioning of Adolescents: Results from the World Trade Center Registry

Gargano L, Dechen T, Cone JE, et al. Journal of Urban Health. March 2017.

Poor school-functioning can be a consequence of poor parent or adolescent mental health or adolescent behavior problems. This study examined the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on school-functioning. Family WTC-exposure was associated with UHCN only by acting through parental mental health. Adolescent mental health, behavioral problems, UHCN, and parental mental health all effected school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health and behavioral problems, as efforts to address any of these alone may not be sufficient.

Intensity of Binge Drinking a Decade After the September 11th Terror Attacks among Exposed Persons

Welch A, Zweig K, McAteer J, et al. Am J Prev Med. 2017;52(2):192-98.

Some people who directly experienced the September 11 attacks in NYC are still suffering from serious mental health problems, including PTSD and excessive alcohol consumption. Data from a 2015-2016 study conducted on over 28,000 WTC Registry enrollees over the age of 18 showed that 25% reported binge drinking in the past month. This is 1.5 times greater than the proportion of NYC adults reporting binge drinking. Of those who said they had engaged in binge drinking, more than one-third reported high intensity binge drinking which means they had more than eight drinks on one occasion. People with PTSD were two times more likely to binge drink with high intensity than to not binge drink at all compared to people without PTSD. In this study, certain groups were more likely to report high intensity binge drinking: People with PTSD, those who participated in rescue and recovery work, and those with 9/11-related injuries and other traumatic exposures. It is important therapy addresses both PTSD symptoms and excessive alcohol use. Policy strategies aimed at reducing access to and the consumption of alcohol are other ways to help reduce binge drinking. Improving access to treatment of PTSD and alcohol use will help people who binge drink and have PTSD lead happier and healthier lives.

Asthma Control in Adolescents 10 to 11 Years After Exposure to the World Trade Center Disaster

Gargano LM, Thomas PA, Stellman SD. Pediatr Res. 2017;81(1-1):43-50.

Little is known about asthma control in adolescents who were exposed to the World Trade Center (WTC) attacks of 9/11/2001 and diagnosed with asthma after 9/11. This study examined asthma and asthma control 10-11 years after 9/11 among exposed adolescents. Similar to previous studies, post 9/11 asthma was associated with dust cloud exposure on 9/11. Poorly/very poorly controlled asthma was significantly higher among adolescent living in a household with income of ≤$75,000, had unmet healthcare needs, and who screened positive for at least one mental health condition. The impact of having at least one mental health condition on the level of asthma control was substantially greater in females than in males.

Substance Use in Adolescents 10 Years after the World Trade Center Attacks in New York City

Gargano LM, Thomas PA, Stellman. SD Journal of Child & Adolescent Substance Abuse. 2017;26(1):66-74.

This study examined prevalence of and factors associated with substance use 10-11 years post-9/11 among adolescents in the World Trade Center Health Registry. Adolescents who witnessed a disturbing event on 9/11 were twice as likely to report ever drinking and almost three times as likely to have ever used marijuana. Among those ≥5 years of age on 9/11, fear for personal safety on 9/11 was significantly associated with having ever smoked cigarettes, ever drank, and ever used marijuana. Intervention and education for adolescents particularly focused on substance use and coping strategies, may be warranted after large-scale disasters.

Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade Center Health Registryr

Gargano Lisa, Gershon RR, Brackbill RM. PLoS Curr. 2016;8.

Interviews with person injured on 9/11 found that even after the injury has healed, injured disaster survivors continue to have long-term health impacts from their experience. Some injured disaster survivors report having serious physical and mental health problems, economic problems due to loss of livelihood, limited sources of social support. A few survivors reported profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery.

Risk Factors for and Consequences of Persistent Lower Respiratory Symptoms among World Trade Center Health Registrants 10 Years after the Disaster

Friedman SM, Farfel MR, Maslow C, et al. Occup Environ Med. 2016; 73(10);676-84.

Many of our studies have found that people who were exposed to the 9/11 disaster have lower respiratory symptoms persisting five to six years after 9/11. We wanted to investigate if Registry enrollees continue to experience the same symptoms ten or more years later.

These symptoms include:

  • Persistent Cough
  • Wheezing
  • Shortness of Breath

More than 12% of 18,913 adult enrollees reported lower respiratory symptoms during the 30 days prior to completing the surveys. Half of those with persistent lower respiratory symptoms screened positive for one or more mental health conditions such as PTSD, depression, or anxiety. Lower respiratory symptoms accompanied by mental health conditions decreased quality of life persistent for at least ten years after 9/11. We recommended that WTC exposed adults continue to be monitored for both respiratory and mental health conditions and treated for both categories of illness.

Effect of Asthma and PTSD on Persistence and Onset of Gastroesophageal Reflux Symptoms among Adults Exposed to the September 11, 2001, Terrorist Attacks

Li J, Brackbill RM, Jordan HT, et al. Am J Ind Med. 2016;59(9):805-814.

Increased rates of GERS, asthma, and posttraumatic stress disorder (PTSD) have been frequently reported in those exposed to 9/11. Few studies have explored the interrelationships among these three conditions. Our study found that asthma and PTSD were each independently associated with both the persistence of GERS that was present at the time of 9/11, as well as development of GERS in persons without a prior history. Posttraumatic stress symptoms may also play a role in the association between asthma and late-onset GERS. These findings suggest that integrated physical and mental care could lessen the longer-term health effects of 9/11.

Impact of 9/11-Related Chronic Conditions and PTSD Comorbidity on Early Retirement and Job Loss among World Trade Center Disaster Rescue and Recovery Workers

Yu S, Brackbill RM, Locke S, et al. Am J Ind Med. 2016;59(9):731-741.

This study focused on the economic impact of the 9/11 terrorist attacks. We looked at the association between 9/11-related chronic health conditions with or without PTSD and early retirement and job loss. A total of 7,662 non-uniformed rescue/recovery workers, such as volunteers, construction workers, healthcare staff, finance, and environmental services workers were studied. We found that workers with chronic conditions were more likely to experience early retirement and job loss, and the likelihood increased considerably when the worker also had PTSD. Disasters like 9/11 terrorist attacks have a large ripple effect on one’s overall well-being through health, employment, and earnings. Future evaluation of disaster impact should extend beyond the direct and short-term health consequences and include its long-term impact on labor force.

Mental Health Status Of World Trade Center Tower Survivors Compared to Other Survivors A Decade After the September 11, 2001 Terrorist Attacks

Gargano LM, Nguyen AM, DiGrande L, et al. Am J Ind Med. 2016;59(9):742-51.

This study compared the current mental health status of persons who were in the World Trade Center (WTC) towers, other surrounding buildings, or on the street the morning of the September 11th terrorist attacks. Those in the WTC towers were at increased risk for post-traumatic stress disorder (PTSD) and frequent binge drinking. Infrastructure and behavioral barriers experienced during evacuation were significantly associated with PTSD. Understanding the effects of disaster-related evacuation barriers on the long-term mental health status of survivors can help in the planning of continuing post-disaster treatment.

Ten-Year Cancer Incidence in Rescue/Recovery Workers and Civilians Exposed to the September 11, 2001 Terrorist Attacks on the World Trade Center

Li J, Brackbill RM, Liao TS, et al. Am J Ind Med. 2016;59(9):709-21.

Since its inception, cancer surveillance has been a priority for the World Trade Center Health Registry. The Registry first examined cancer incidence from 2003 to 2008 in a study that found more cases than expected of prostate cancer, thyroid cancer, and multiple myeloma among rescue/recovery workers enrolled in the Registry, compared to the general New York State population. The article “Ten-year cancer incidence in rescue/recovery workers and civilians exposed to the September 11, 2001 terrorist attacks on the World Trade Center” presents findings from a follow up study of cancer incidence.

The study found that for all cancer sites combined from 2007-2011, there were 11 percent more cancer cases than expected among rescue/recovery workers, and 8 percent more among civilian survivors compared with the New York State general population. Prostate and thyroid cancer remained elevated among rescue/recovery workers. There were also small, but higher than expected, incidence of skin melanoma in rescue/recovery workers and non-responder civilian survivors. Among civilian survivors, the study found elevated incidence of female breast cancer and non-Hodgkin’s lymphoma. The findings also provide limited evidence for a causal link between 9/11 exposure and cancer. These findings need to be substantiated by additional follow up studies over time.

Asthma among Staten Island Fresh Kills Landfill and Barge Workers following the September 11, 2001 World Trade Center Terrorist Attacks

Cone JE, Osahan S, Ekenga CC, et al. Am J Ind Med. 2016;59(9):795-804.

To evaluate the risk of asthma first diagnosed among Staten Island landfill and barge workers, we conducted a survey and multivariable logistic regression analysis regarding the association between Staten Island landfill and barge-related work exposures and the onset of post-9/11 asthma. Asthma newly diagnosed between 9/11/01-12/31/04 was reported by 100/1836 (5.4%) enrollees. Jobs involving sifting, digging, welding, and steel cutting, enrollees with high landfill/barge exposure index scores or who were police and sanitation workers, and enrollees with probable posttraumatic stress disorder all had increased odds ratios for new-onset asthma.

Post-9/11 asthma cumulative incidence among Staten Island landfill/barge workers was similar to that of other WTC disaster rescue and recovery workers.

A PTSD Symptoms Trajectory Mediates Between Exposure Levels and Emotional Support in Police Responders To 9/11: A Growth Curve Analysis

Schwarzer R, Cone JE, Li J, et al. BMC Psychiatry. 2016;16:201.

This paper examined the relationship between initial exposure levels, long-term PTSD symptoms, and subsequent emotional support among police responders. The study population included police responders who had reported their 9/11 exposure levels at Wave 1 (2003/4), provided three waves of data on PTSD symptoms using the 17-item PCL scale, and rated their received emotional support at Wave 3 (N=2,204, 1,908 men, 296 women, mean age: 38 years at exposure). A second-order growth curve reflected a PTSD symptom trajectory which was embedded in a structural equation model, with exposure level specified as an exogenous predictor, and emotional support specified as an endogenous outcome. Exposure had a main effect on mean symptom levels (intercept) across three waves but it made no difference in changes in symptoms (slope), and no difference in emotional support. The symptom trajectory, on the other hand, had an effect on emotional support. Its intercept and slope were both related to support, indicating that changes in symptoms affected later emotional support. Initial trauma exposure levels can have a long-term effect on mean symptom levels. Emotional support is lower in police responders when PTSD symptoms persist over seven years, but becomes higher when reduction in symptoms occurs.

Hurricane Sandy Evacuation Among World Trade Center Health Registry Enrollees in New York City

Brown S, Gargano LM, Parton H, et al. Disaster Med Public Health Prep. 2016 Apr 21:1-9.

This study examined factors associated with evacuation and evacuation timing during Hurricane Sandy. Among respondents who evacuated for Hurricane Sandy (51%), 24% had evacuated before the storm. Those more likely to evacuate knew they resided in an evacuation zone, had evacuated during Hurricane Irene, or reported pre-Sandy community cohesion. Evacuation was less likely among those who reported being prepared for an emergency. For evacuation timing, evacuation before Hurricane Sandy was less likely among those with pets and those who reported 14 or more poor physical health days. Higher evacuation rates were observed for respondents seemingly more informed and who lived in neighborhoods with greater social capital. Improved disaster messaging that amplifies these factors may increase adherence with evacuation warnings.

Police Officers Who Responded to 9/11: Comorbidity of PTSD, Depression, and Anxiety 10-11 Years Later

Bowler RM, Kornblith ES, Li J, et al. Am J Ind Med. 2016 Jun;59(6):425-36. doi: 10.1002/ajim.22588. Epub 2016 Apr 20

We examined comorbidity of PTSD, depression, and/or anxiety among police enrollees (N=1,884) from the WTC Health Registry. Categorized into four groups based on comorbidity of PTSD, depression, and anxiety. DSM-IV diagnostic criteria for PTSD were used. Depression (PHQ-8) and anxiety (GAD-7) were assessed with standardized psychometric inventories. Multinomial logistic regression was used to identify putative risk factors associated with comorbidity of PTSD. Of 243 (12.9% of total) police with probable PTSD, 21.8% had probable PTSD without comorbidity, 24.7% had depression, 5.8% had anxiety, and 47.7% had comorbid depression and anxiety. Risk factors for comorbid PTSD, depression, and anxiety include being Hispanic, decrease in income, experiencing physical injury on 9/11, experiencing stressful/traumatic events since 9/11, and being unemployed/retired. Nearly half of police with probable PTSD had comorbid depression and anxiety.

Trajectories of PTSD Among Lower Manhattan Residents and Area Workers Following the 2001 World Trade Center Disaster, 2003-2012.

Welch AE, Caramanica K, Maslow CB, et al. J Trauma Stress. 2016 Apr;29(2):158-66. doi: 10.1002/jts.22090. Epub 2016 Mar 8.

The majority of the hundreds of thousands of people directly exposed to the September 11th terror attacks in NYC were civilians and were not involved in rescue/recovery work. Because earlier studies showed that PTSD was one of the most common health conditions up to 6 years after 9/11, we examined longer-term patterns of PTSD symptoms over a nine year period among 17,000 civilians enrolled in the WTC Health Registry. Most civilians had few or no PTSD symptoms; however, one in four had PTSD at some point during the study period. Some people with PTSD had symptoms that improved, however most had symptoms that either persisted or got worse over time. PTSD that persisted or worsened was more common among enrollees with low education and social support, or who had high WTC exposure, were unemployed or were unable to get the mental health care they needed.

Chronic Probable PTSD in Police Responders in the World Trade Center Health Registry Ten to Eleven Years After 9/11

Cone JE, Li J, Kornblith E, et al. Am J Ind Med. 2015 May;58(5):483-93. doi: 10.1002/ajim.22446.

The current study documents the longitudinal trajectories of PTSD in police officers exposed to the WTC attacks at Wave 3 (2011–2012), over 10 years since the WTC attack. We examined the prevalence of probable PTSD at the Wave 3. Probable PTSD was 14.4% (95% CI 13.0–15.9%) at Wave 2 and 12.9% (95% CI, 11.6–14.3%) at Wave 3. Significant predictors of chronic probable PTSD 10 years post-disaster (n = 59/2241, 2.6%) include age 45–69 (aOR 3.16, 95% CI, 1.7–6.0), number of stressful events witnessed on 9/11/01 (aOR 3.00, 1.6–5.8), five or more stressful life events since 9/11/01 (aOR 5.42, 1.9–15.2), and unmet mental health care needs (aOR 6.86, 3.3–14.1). Protective factors include social support (aOR 0.34, 0.1–0.97) and number of close friends or relatives (aOR 0.92, 0.87–0.98). Chronic probable PTSD among police responders continues to be a significant problem, associated both with intervening stressful life events and unmet mental health care needs.

Cancer in World Trade Center Responders: Findings from Multiple Cohorts and Options for Future Study

Boffetta P, Zeig-Owens R, Wallenstein S, et al. Am J Ind Med. 2016 Feb;59(2):96-105. doi: 10.1002/ajim.22555. Epub 2016 Jan 4.M

This was a review of three longitudinal studies of cancer incidence in WTC rescue/recovery worker populations from three WTCHP programs. The review entailed a detailed comparison of the three study populations, follow-up periods, methods of cancer case identification, exposure assessments, data analysis, as well as the similarity in findings, limitations and potential sources of bias. This paper represents an effort to derive valid epidemiologic results about an important health question despite limitations of the underlying data; and suggested a plan to conduct a pooled analysis of merged cohorts of rescue/recovery workers’ cancer incidence, latency and survival to maximize study power, remove overlap among programs, and systemize interpretation of results.

Factors Associated with Poor Control of 9/11-Related Asthma 10-11 Years after the 2001 World Trade Center Terrorist Attacks

Jordan HT, Stellman SD, Reibman J, et al. Asthma. 2015;52(6):630-7. doi: 10.3109/02770903.2014.999083. Epub 2015 May 22.

This study of approximately 2,500 WTC Health Registry enrollees who were diagnosed with asthma between 9/11 and the end of 2003 found that only about one third of participants had well-controlled symptoms in 2011-12. The factors that were most closely tied to poor asthma control were co-existing mental health conditions. Gastroesophageal reflux and obstructive sleep apnea were also associated with poor control of asthma. These results show that people with 9/11-related asthma continue to experience symptoms a decade after the attacks, and emphasize the importance of integrating care for 9/11-related mental and physical health conditions.

Exposure to the World Trade Center Disaster and 9/11-Related Post-Traumatic Stress Disorder and Household Disaster Preparedness

Gargano LM, Caramanica K, Sisco S, et al. Disaster Med Public Health Prep. 2015 Jun 15:1-9.

This study looked at the level of preparedness for Hurricane Sandy in the 9/11-exposed population, and the relationship between preparedness and disaster-related and non-disaster-related characteristics. Participants were considered prepared if they reported possessing at least 7 of 8 standard preparedness items such as a 3-day supply of water, food, first aid kit, battery-operated radio, medications, flashlight, personal care and hygiene items, and evacuation plan. Over one-third of the 4496 enrollees who participated in the survey were prepared, with 18.8% possessing all eight items. High levels of 9/11 exposure were associated with being prepared. Future preparedness messaging should target people with low social support networks. Communications should include information on evacuation zones and where to find information about how to evacuate.

Evaluation of Non-Response Bias in a Cohort Study of World Trade Center Terrorist Attack Survivors

Yu S, Brackbill RM, Stellman SD, et al. 2015 Feb 15;8(1):42. doi: 10.1186/s13104-015-0994-2.

A study evaluating non-response bias found that, despite a downward bias in prevalence estimates of health outcomes, attrition from the World Trade Center Health Registry follow-up studies does not lead to serious bias in associations between 9/11 disaster exposures and key health outcomes. These findings provide insight into the impact of non-response on associations between disaster exposures and health outcomes reported in longitudinal studies.

Trajectories of Scores on a Screening Instrument for PTSD among World Trade Center Rescue, Recovery, and Clean-Up Workers

Maslow CB, Caramanica K, Welch AE, et al. J Trauma Stress. 2015 May 19. doi: 10.1002/jts.22011.

This study described the course of PTSD symptoms in a cohort of 9/11 responders by identifying five distinct subgroups on the basis of trajectories of scores on the Posttraumatic Disorder Checklist, administered three times over an 8-9 year period. It identified several 9/11-related exposures associated with high likelihood of following specific trajectories, and assessed the impact of changing life circumstances on the course of each trajectory. Responders with higher levels of exposure were more likely to follow less favorable trajectories than were responders with less exposure. Within trajectory groups, responders who endured more adverse personal circumstances during the study period had higher scores than did those with more favorable circumstances. This study highlights the need for immediate and continued periodic screening for both mental health effects of disasters and circumstances that may affect the course of those effects.

Posttraumatic Stress Disorder after Hurricane Sandy among Persons Exposed to the 9/11 Disaster.

Caramanica K, Brackbill RM, Stellman SD, Farfel MR. Compr Psychiatry. Int J Emerg Ment Health. 2015;17(1):356-362.

The Registry provided a sampling pool for a survey of the experiences and physical and mental health of persons directly affected by Hurricane Sandy in the New York City (NYC) metropolitan area in late October 2012; a total of 4,558 Hurricane Sandy surveys were completed from April 10-November 7, 2013. After exclusions for missing data, the final sample included 2,214 (53.5%) respondents from FEMA-defined inundation zones and 1,923 (46.5%) from non-inundation zones. PTSD prevalence was higher in the inundation zones (11.3%) and lower in the non-inundation zones (4.4%). The highest prevalence of Sandy-related PTSD was among individuals in the inundation zone who sustained an injury (31.2%), reported a history of 9/11-related PTSD (28.8%), or had low social support prior to the event (28.6%). In the inundation zones, significantly elevated adjusted odds of Sandy-related PTSD were observed among persons with a prior history of 9/11-related PTSD, low social support, and those who experienced a greater number of Sandy traumatic events.

Comorbidity of 9/11-Related PTSD and Depression in the World Trade Center Health Registry 10-11 Years Postdisaster

Caramanica K, Brackbill RM, Liao T, Stellman SD. J Trauma Stress. 2014 Dec;27(6):680-8. doi: 10.1002/jts.21972. Epub 2014 Dec 2.

A study of 29,486 adult Registry enrollees conducted 10-11 years post-9/11 found that 15.2% screened positive for probable PTSD at Wave 3, 14.9% for depression, and 10.1% for both. Comorbid PTSD and depression was associated with high 9/11 exposures, low social integration, unemployment for health reasons, and experiencing more than one traumatic life event since 9/11. Comorbid persons experienced poorer outcomes on all PTSD-related impairment measures and symptom duration, life satisfaction, overall health, and perceived unmet mental health care need compared to those with PTSD or depression only.

Nonfatal Injuries 1 Week After Hurricane Sandy—New York City Metropolitan Area, October 2012

Brackbill RM, Caramanica K, Maliniak M, et al. MMWR Morb Mortal Wkly Rep. 2014 Oct 24;63(42):950-4.

The study looked at injuries sustained in the first week after Hurricane Sandy hit New York City area on October29, 2012. The degree of flooding in the home or surrounding area was directly related to the occurrence of injury, with 39% of those who evacuated by walking through water or swimming being injured, and 25% of those whose homes were flooded with 3 or more feet of water, regardless of whether they did or did not evacuate. Additionally, the greatest number injuries occurred among persons who had a damaged or destroyed home and attempted to do clean-up or repair work.

Frequent Binge Drinking Five to Six Years After Exposure to 9/11: Findings from the World Trade Center Health Registry

Welch AE, Caramanica K, Maslow CB, Cone JE, Farfel MR, Keyes KM, Stellman SD, Hasin DS. Drug Alcohol Depend. 2014 Apr 28. pii: S0376-8716(14)00839-4. doi: 10.1016/j.drugalcdep.2014.04.013.

Many of our Registry enrollees and other exposed persons developed PTSD after 9/11 and as a consequence may be drinking excessively. We looked at the survey responses from about 41,000 Registry enrollees, to examine the relationship between PTSD, extent of exposure to the 9/11 disaster, and frequent binge drinking, which was defined as having five or more drinks on a single occasion on five or more days of the past month. Frequent binge drinking was reported by fifteen percent of those suffering from PTSD, and only six percent of those without PTSD. People with higher levels of exposure to the 9/11 disaster were more likely to report frequent binge drinking than people with lower exposures. We now have a better understanding of the impact of PTSD and different levels of 9/11 exposure on how often people engage in binge drinking.

Posttraumatic Stress Disorder and New-Onset Diabetes Among Adult Survivors of the World Trade Center Disaster

Miller-Archie SA, Jordan HT, Ruff RR, Chamany S, Cone JE, Brackbill RM, Kong J, Ortega FM, Stellman SD. Prev Med. 2014 May 28. pii: S0091-7435(14)00182-0. doi: 10.1016/j.ypmed.2014.05.016.

A study of over 36,000 Registry enrollees found that those who had PTSD when they joined in 2003-2004 were 30 percent more likely to develop diabetes six to eight years later than people without PTSD. One explanation is that chronic stress reactions caused by PTSD can, over time, cause the body’s cells to become resistant to insulin, causing sugar to build up in the bloodstream. PTSD has also been associated with unhealthy behaviors including poor diet and physical inactivity, both of which may increase the risk of developing diabetes.

Unmet Mental Health Care Need 10-11 Years After the 9/11 Terrorist Attacks: Results from 2011-2012 World Trade Center Health Registry

Ghuman SJ, Brackbill RM, Stellman SD, et al. BMC Public Health. 2014 May 22;14(1):491.

A study investigating the mental health care needs of 30,000 Registry enrollees 10 to 11 years after 9/11 found: over 15 % reported having PTSD, nearly 15% percent experienced depression, and 10% percent had both conditions.

Enrollees who reported having both PTSD and depression were more likely to have increased 9/11 exposure, be unemployed, have lower social support and quality of life and have more unmet mental health care needs. It is common for traumatized populations to suffer from both PTSD and depression; the combination is often associated with functional impairment, greater symptom severity and disability.

Cardiovascular Disease Hospitalizations in Relation to Exposure to the September 11, 2001 World Trade Center Disaster and Posttraumatic Stress Disorder

Jordan HT, Stellman SD, Morabia A et al. Journal of the American Heart Association. 2013 Oct 24;2(5):e000431. doi: 10.1161/JAHA.113.000431.

An exploratory study found that two to six years after the 9/11 disaster, measures of dust exposure, injury on 9/11 and PTSD each were associated with an elevated risk of non-fatal heart disease among adult enrollees.

Reply to Comment on Exposure on September 11, 2001, and Cancer Risk

Stellman SD, Li J. Journal of the American Medical Association. 2013 Apr 3;309(13):1344. doi: 10.1001/jama.2013.2240.

Response to Dr. Reich’s Letter: Sarcoidosis and World Trade Center Disaster

Jordan HT, Osahan SS, Cone JE et al. Journal of Occupational and Environmental Medicine. 2012;54(1):2-3.

Invited reply to "PTSD is a risk factor for cardiovascular disease

Jordan HT, Miller-Archie SA, Cone JE et al. Preventive Medecine. 2012 Mar 12.

Chronic Physical Health Consequences of Being Injured During the Terrorist Attacks on World Trade Center on September 11, 2001

Brackbill RM, Cone JE, Farfel MR, Stellman SD. American Journal of Epidemiology. 2014 Feb 20.

Enrollees with injuries as a result of 9/11, including broken bones, burns, and head trauma, were found to be at increased risk of chronic disease five to six years later. This study included more than 14,000 adult enrollees who reported no previous diagnosis of heart disease, respiratory disease, diabetes or cancer. The nearly 2,000 enrollees who reported more than one type of injury were twice as likely to also report a respiratory illness as those who were not injured. Enrollees with multiple types of injuries and probable post-traumatic stress disorder (PTSD) were three times more likely to report heart disease than those without injuries and PTSD.

Respiratory Protective Equipment, Mask Use, and Respiratory Outcomes Among World Trade Center Rescue and Recovery Workers

Antao VC, Pallos LL, Shim YK et al (2011). American Journal of Industrial Medicine. 2011 Sep 19. doi: 10.1002/ajim.21009.

Longitudinal Mental Health Impact Among Police Responders to the 9/11 Attack. American Journal of Industrial Medicine

Bowler RM, Harris M, Li J et al (2011). 2011 Dec 27. doi: 10.1002/ajim.22000.

A longitudinal study of nearly 3,000 police responders found that PTSD prevalence doubled from 7.8% in 2003-04 to 16.5% in 2006-7. Female police were significantly more likely than male police to report PTSD symptoms in the first survey, but this gender difference disappeared by the second survey. PTSD risk factors included post 9/11 unemployment and disability.

Gender Differences in Probable Posttraumatic Stress Disorder Among Police Responders to the 2001 World Trade Center Terrorist Attack

Bowler RM, Han H, Gocheva V et al (2010). American Journal of Industrial Medicine, 2010; 53(12):1186-96.

Asthma and Posttraumatic Stress Symptoms 5 to 6 Years Following Exposure to the World Trade Center Terrorist Attack

Brackbill RM, Thorpe LE, DiGrande L, et al (2006). Morbidity and Mortality Weekly Report Surveillance Summary. 2006;, 55, 1-18.

Mental Health of Those Directly Exposed to the World Trade Center Disaster: Unmet Mental Health Care Need, Mental Health Treatment Service Use, and Quality of Life

Brackbill RM, Stellman SD, Perlman SE et al. Social Science & Medicine. 2013 Jan 3. pii: S0277-9536(12)00839-8. doi: 10.1016/j.socscimed.2012.12.016.

High levels of unmet mental health needs and poor mental health days were reported by adult enrollees with probable PTSD symptoms five to six years after 9/11, especially among those who also reported being diagnosed with a mental health condition. However, those with a mental health condition are a vulnerable group. They were much less likely to use mental health services despite having perceived a need for mental health care.

World Trade Center Health Registry--A Model for a Nanomaterials Exposure Registry

Cone JE & Farfel M (2011). Journal of Occupational and Environmental Medicine. 2011;53(6 Suppl):S48-51.

Comparison of health outcomes among affiliated and lay disaster volunteers enrolled in the World Trade Center Health Registry

Debchoudhury I, Welch AE, Fairclough MA et al (2011). Preventive Medicine. 2011 Sept 10.

Long-term Posttraumatic Stress Symptoms Among 3,271 Civilian Survivors of the September 11, 2001, Terrorist Attacks on the World Trade Center

DiGrande L, Neria Y, Brackbill RM et al (2011).  American Journal of Epidemiology. 2011;173(3):271-81.

Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2-3 years after the September 11, 2001 terrorist attacks

DiGrande L, Perrin M, Thorpe L, et al (2008).  Journal of Traumatic Stress. 2008;, 21(3), 264-73.

Tasks of Landfill and Barge Workers: Qualitative Analysis from the World Trade Center Health Registry

Ekenga CC, Scheu KE, Cone JE et al (2011).  BMC Public Health. 2011;11:321.

An Overview of 9/11 Experiences and Respiratory and Mental Health Conditions among World Trade Center Health Registry Enrollees

Farfel M, DiGrande L, Brackbill R, et al (2008).  Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2008;85(6),: 880-909.

Case-Control Study of Lung Function in World Trade Center Health Registry Area Residents and Workers

Friedman SM, Maslow CB, Reibman J et al (2011. American Journal of Respiratory Critical Care Medicine. 2011;184(5):582-9.

Comorbid Persistent Lower Respiratory Symptoms and Posttraumatic Stress Disorder 5-6 years Post-9/11 in Responders Enrolled in the World Trade Center Health Registry

Friedman SM, Farfel MR, Maslow CB et al.  American Journal of Industrial Medicine. 2013 Jun 21. doi: 10.1002/ajim.22217.

A study of 14,388 rescue and recovery workers five to six years after 9/11 found that 40% of those with lower respiratory symptoms and 57 percent of those with likely posttraumatic stress disorder (PTSD) had both types of symptoms. Rescue and recovery workers with this combination, or comorbidity, had more severe illness than responders with respiratory symptoms alone or probable PTSD alone. Responders who were comorbid were about three times more likely to report fair or poor general health, and twice as likely to report being unable to perform usual activities for 14 or more days in the month before completing their 2006-2007 survey. Given the comorbidity of respiratory and probable PTSD symptoms, health care providers are strongly encouraged to address both mental and physical health outcomes among persons exposed to a disaster, such as the 9/11 disaster.

Evacuating Damaged and Destroyed Buildings on 9/11: Behavioral and Structural Barriers

Groeger JL, Stellman SD, Kravitt A & Brackbill RM.  Prehospital & Disaster Medicine.2013 Nov 19:1-11.

Self-Reported Skin Rash or Irritation Symptoms Among World Trade Center Health Registry Participants

Huang MJ, Li J, Liff JM et al (2012). Journal of Occupational and Environmental Medicine. 2012 Mar 22.

Twelve percent of 42,025 Registry adult enrollees reported post-9/11 skin rash in 2003-04, 16% reported skin rash in 2006-07 and 6% reported it at both times. Among enrollees without PTSD or other psychological distress, increased risk for early skin rash was independently associated with intense dust cloud exposure, damage to the home or workplace, and working at least 31 days at the WTC site.

Mortality Among Survivors of the Sept 11, 2001, World Trade Center Disaster: Results from the World Trade Center Health Registry Cohort

Jordan HT, Brackbill RM, Cone JE et al (2011).  Lancet. 2011; 378(9794):879-87.

Sarcoidosis Diagnosed After September 11, 2001, Among Adults Exposed to the World Trade Center Disaster

Jordan HT, Stellman SD, Prezant D et al (2011).  Journal of Occupational and Environmental Medicine. 2011 Aug 19.

Heart Disease among Adults Exposed to the September 11, 2001 World Trade Center Disaster: Results from the World Trade Center Health Registry

Jordan HT, Miller-Archie SA, Cone JE et al (2011).  Preventive Medicine. 2011 Oct 28.

Association between World Trade Center Exposure and Excess Cancer Risk

Li J, Cone JE, Kahn AR et al.  Journal of the American Medical Association. 2012 Dec 19;308(23):2479-88.

The Registry’s first cancer analysis found that the overall cancer rate in 2007-2008 among people directly exposed to the 9/11 disaster was not different than that of New York State residents during this period. The study, however, did find small increases in rates of three types of cancer—prostate cancer, thyroid cancer, and multiple myeloma—among rescue/recovery workers during this period. This study analyzed cancer diagnoses among nearly 56,000 adult Registry enrollees who resided in New York State at the time of their enrollment.

Gastroesophageal Reflux Symptoms and Comorbid Asthma and Posttraumatic Stress Disorder Following the 9/11 Terrorist Attacks on World Trade Center in New York City

Li J, Brackbill RM, Stellman SD et al (2011).  American Journal of Gastroenterology. 2011 Sep 6. doi: 10.1038/ajg.2011.300.

Birth Outcomes Among Offspring of Women Exposed to the September 11, 2001, Terrorist Attacks

Lipkind HS, Curry, AE, Huynh M et al (2010).  Obstetrics & Gynecology. 2010;116(4):917-925.

Chronic and Acute Exposures to the World Trade Center Disaster and Lower Respiratory Symptoms: Area Residents and Workers

Maslow CB, Friedman SM, Pillai PS et al. (2012.  American Journal of Public Health. 2012 Apr 19.

A Registry case control study of nearly 800 Lower Manhattan residents and area workers found that both acute and chronic WTC exposures were independently associated with lower respiratory symptoms up to six years after 9/11. The risk for lower respiratory symptoms increased both with the severity of dust cloud exposure and the thickness of dust in the home or workplace.

Estimating the World Trade Center tower population on September 11, 2001: A Capture—Recapture Approach

Murphy J. (2009).  American Journal of Public Health. 2009; 99(1): 65-7.

Measuring and maximizing coverage in the World Trade Center Health Registry

Murphy J, Brackbill RM, Thalji L., et al (2007).  Statistics In Medicine. 2007; 26, 1688-701.

Co-occurring Lower Respiratory Symptoms and Posttraumatic Stress Disorder 5 to 6 Years After the World Trade Center Terrorist Attack

Nair HP, Ekenga CC, Cone JE et al. (2012).  American Journal of Public Health. 2012 Aug 16.
More than 25% of residents, office workers, and passers-by enrolled in the Registry who had either lower respiratory symptoms or probable post-traumatic stress disorder (PTSD) had both conditions five to six years after 9/11. Also, enrollees who had both conditions were much more likely to report 14 days of activity lost in the 30 days before being surveyed than enrollees with one of these conditions.

Short-term and medium-term health effects of 9/11

Perlman SE, Friedman S, Galea S et al (2011).  Lancet. 2011 378(9794):925-34.

Differences in PTSD prevalence and associated risk factors among World Trade Center rescue and recovery workers

Perrin MA, DiGrande L, Wheeler K, et al (2007).  The American Journal of Psychiatry. 2007; 164, 1385-1394.

Social Integration Buffers Stress in New York Police after the 9/11 Terrorist Attack

Schwarzer R, Bowler RM, Cone JE (2013).  Anxiety Stress Coping. 2013 Jun 8.

Being socially integrated is regarded as a protective factor enabling people to cope with adversity. This study, based on 2943 police officers, examines Posttraumatic Stress Disorder (PTSD) among officers who responded to the 9/11 terrorist attack on the World Trade Center. A model was specified that uses 9/11 horrific event exposure as a predictor, earlier (Wave 1 WPTSD) response as a mediator, and later (Wave 2 PTSD) response as an outcome, and social integration as a moderator of this relationship. We found a multiplicative relationship between exposure levels and social integration: The higher the exposure level, the more stress responses occur, but this effect was buffered by a high level of social integration. Wave 1 PTSD interacted with social integration on Wave 2 PTSD: The more the police officers were socially integrated, the lower the Wave 2 PTSD score. The findings contribute to the understanding of mediating and moderating mechanisms that result in health outcomes such as posttraumatic stress disorder or resilience.

Respiratory Health of 985 Children Exposed to the World Trade Center Disaster: Report on World Trade Center Health Registry Wave 2 Follow-up, 2007-2008.

Stellman SD, Thomas PA, Osahan S et al. Journal of Asthma. 2013 Feb 18.

Respiratory symptoms six to seven years after 9/11 were associated with 9/11 dust cloud exposure in younger children and with behavior problems in adolescents. Other risk factors for respiratory symptoms included living in low-income households.

Respiratory and Other Health Effects Reported in Children Exposed to the World Trade Center Disaster of September 11, 2001

Thomas P, Brackbill R, Thalji L, et al (2008  Environmental Health Perspectives. 2008; 116(10):1383-1390. 

Health Consequences of the World Trade Center Disaster: a 10th Anniversary Perspective

Thorpe LE, Friedman S.(2011).  Journal of the American Medical Association. 2011;306(10):1133-4.

The Public Health Response to the World Trade Center Attack and its Aftermath by the New York City Department of Health and Mental Hygiene.

Weisfuse IB, Marsik T, Brackbill RM. (2011). In: Levy BS, Sidel WV, eds. Terrorism and Public Health. 2nd ed. New York, NY: Oxford University Press; 2011:43-66.
Report (PDF)

A Qualitative Examination of Health and Health Care Utilization after the September 11th Terror Attacks among World Trade Center Health Registry Enrollees

Welch AE, Caramanica K, Debchoudhury I et al. (2012).    BMC Public Health. 2012 Aug 31;12(1):721.

In focus groups with both responders and survivors, participants reported barriers that prevented them from accessing 9/11 services: lack of visibility and accessibility of 9/11 health programs; fear of stigma related to receiving mental health care; unfamiliarity with 9/11-related health conditions; and few referrals from primary care providers.

Asthma Diagnosed after September 11, 2001 among rescue and recovery workers

Wheeler K, McKelvey W, Thorpe L, et al (2007. Environmental Health Perspectives. 2007; 115; 1584-1590.

Technical Reports

Clinical Guidelines


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