Mortality among Fire Department of the City of New York Rescue and Recovery Workers Exposed to the World Trade Center Disaster, 2001-2017

World Trade Center (WTC) Exposures and Cardiometabolic Risk Among WTC Health Program General Responders

Objectives. To assess the association between World Trade Center (WTC) exposures, cardiometabolic diseases (CMDs), and trajectories of glucose and systolic blood pressure (SBP) among WTC Health Program general responders (WTHPGR). Methods. We included monitoring visits (2003-2021) of WTHPGR who participated in the operations in New York City after the September 11, 2001, attack (n = 47 795). The WTC Health Program assessed WTC exposures using questionnaires and measured trajectories during monitoring study visits; CMDs were self-reported. We assessed associations with CMDs (hazard ratios and their corresponding 95% confidence intervals [CIs]) using survival analyses. We assessed associations with trajectories (odds ratios and their corresponding 95% CIs) using logistic regressions. Results. Interquartile range (IQR) increases in the number of days on-site in the 9 months following the attack were associated with increased diabetes (1.057; 95% CI = 1.025, 1.089) and hypertension (1.035; 95% CI = 1.014, 1.057) risks. IQR increases in hours on-site during September 2001 were associated with worsening glucose (1.040; 95% CI = 1.017, 1.064) and SBP (1.006; 95% CI = 1.001, 1.010) trajectories. Conclusions. WTC exposures are associated with higher CMD risk and worsening cardiometabolic trajectories among WTHPGR. Public Health implications. Linking WTC exposures to emerging diseases is vital because of its impact on health care costs and treatment access among WTHPGR. (Am J Public Health. Published online ahead of print May 15, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308079).

Exposure-Informed Care Following Toxic Environmental Exposures: A Lifestyle Medicine Approach

Exposure to environmental toxins presents substantial health risks, particularly for individuals facing heightened exposure due to occupational hazards. This analytic review highlights the critical need to address these risks through a lifestyle medicine approach, advocating for integrated care strategies to mitigate the long-term health impacts of toxic environmental exposures. We explore exposures to environmental toxins in 2 at-risk populations, military service members exposed to airborne hazards and burn pits during overseas deployments and first responders to the World Trade Center terrorist attack. The review highlights the immediate and long-term chronic health effects of toxic environmental exposures, emphasizing the variable symptoms, long latency, and long-term complex outcomes that necessitate an exposure-informed health care model. Exposure-informed care can enhance overall well-being and reduce the risks of chronic illnesses by incorporating lifestyle medicine principles supported by a learning community system. The proposed model makes recommendations for a shift to exposure-informed preventative care. This enhanced approach aims to promote a longer and healthier life for those at increased risks following toxic environmental exposures. Understanding the context of military burn pit and World Trade Center environmental exposures and the possibilities of exposure-informed care is paramount in shifting from a traditional disease-centered model to a holistic, person-centered approach.

Trace and Major Element Concentrations in Cadaveric Lung Tissues from World Trade Center Health Registry Decedents and Community Controls

Studies of the health impacts of the 11 September 2001 terrorist attacks on New York City's (NYC's) World Trade Center (WTC) towers have been hindered by imprecise estimates of exposure. We sought to identify potential biomarkers of WTC exposure by measuring trace and major metal concentrations in lung tissues from WTC-exposed individuals and less exposed community controls. We also investigated associations of lung tissue metal concentrations with self-reported exposure and respiratory symptoms. The primary analyses contrasted post-mortem lung tissue concentrations obtained from autopsies in 2007-2011 of 76 WTC Health Registry (WTCHR) enrollees with those of 55 community controls. Community controls were frequency-matched to WTCHR decedents by age at death, calendar quarter of death, gender, race, ethnicity and education and resided at death in NYC zip codes less impacted by WTC dust and fumes. We found WTCHR decedents to have significantly higher iron (Fe) lung tissue concentrations than community controls. Secondary analyses among WTCHR decedents adjusted for sex and age showed the log(molybdenum (Mo)) concentration to be significantly associated with non-rescue/recovery exposure. Post hoc analyses suggested that individuals whose death certificates listed usual occupation or industry as the Sanitation or Police Departments had elevated lung tissue Fe concentrations. Among WTCHR decedents, exposure to the WTC dust cloud was significantly associated with elevated lung tissue concentrations of titanium (Ti), chromium (Cr) and cadmium (Cd) in non-parametric univariable analyses but not in multivariable analyses adjusted for age and smoking status. Logistic regression adjusted for age and smoking status among WTCHR decedents showed one or more respiratory symptoms to be positively associated with log (arsenic (As)), log(manganese (Mn)) and log(cobalt (Co)) concentrations, while new-onset wheezing and sinus problems were negatively associated with log(Fe) concentration. Fe concentrations among individuals with wheezing, nonetheless, exceeded those in community controls. In conclusion, these data suggest that further research may be warranted to explore the utility as biomarkers of WTC exposure of Fe in particular and, to a lesser extent, Mo, Ti, Cr and Cd in digestions of lung tissue.

Correction: Colbeth et al. Mortality among Fire Department of the City of New York Rescue and Recovery Workers Exposed to the World Trade Center Disaster, 2001-2017. Int. J. Environ. Res. Public Health 2020, 17, 6266

The original publication [...].

Association of Lung Function Decline with All-Cause and Cancer-Cause Mortality after World Trade Center Dust Exposure

Rationale: In numerous cohorts, lung function decline is associated with all-cause and cardiovascular-cause mortality, but the association between the decrease in forced expiratory volume in 1 second (FEV1) and cancer-cause mortality, particularly after occupational/environmental exposure(s), is unclear. Exposure to dust/smoke from the World Trade Center (WTC) disaster caused inflammation and lung injury in Fire Department of the City of New York rescue/recovery workers. In addition, prior research found that >10% of the cohort experienced greater than twice the age-related decrease in FEV1 (⩾64 ml/yr). Objectives: To evaluate the association of longitudinal lung function with all-cause and cancer-cause mortality after exposure to the WTC disaster. Methods: We conducted a prospective cohort study using longitudinal prebronchodilator FEV1 data for 12,264 WTC-exposed firefighters and emergency medical service providers. All-cause and cancer-cause mortality were ascertained using National Death Index data from September 12, 2001, through December 31, 2021. Joint longitudinal survival models evaluated the association of baseline FEV1 and change in FEV1 from baseline with all-cause and cancer-cause mortality adjusted for age, race/ethnicity, height, smoking, work assignment (firefighters vs. emergency medical service providers), and WTC exposure. Results: By December 31, 2021, 607 of the 12,264 individuals in the cohort (4.9%) had died (crude rate = 259.5 per 100,000 person-years), and 190 of 12,264 (1.5%) had died from cancer (crude rate = 81.2 per 100,000 person-years). Baseline FEV1 was ⩾80% predicted in 10,970 of the 12,264 (89.4%); final FEV1 was ⩾80% in 9,996 (81.5%). Lower FEV1 at baseline was associated with greater risk for all-cause mortality (hazard ratio [HR] per liter = 2.32; 95% confidence interval [95% CI] = 1.98-2.72) and cancer-cause mortality (HR per liter = 1.99; 95% CI = 1.49-2.66). Longitudinally, each 100-ml/yr decrease in FEV1 was associated with an 11% increase in all-cause mortality (HR = 1.11; 95% CI = 1.06-1.15) and a 7% increase in cancer-cause mortality (HR = 1.07; 95% CI = 1.00-1.15). Compared with FEV1 decrease <64 ml/yr, those with FEV1 decrease ⩾64 ml/yr had higher all-cause (HR = 2.91; 95% CI = 2.37-3.56) and cancer-cause mortality (HR = 2.68; 95% CI = 1.90-3.79). Conclusions: Baseline FEV1 and longitudinal FEV1 decrease are associated with increased risk of all-cause and cancer-cause mortality in a previously healthy occupational cohort, the majority of whom had normal lung function, after intense exposure to dust/smoke. Further investigation is needed to define pathways by which lung function impacts mortality after an irritant exposure.

Firefighting and Cancer: A Meta-analysis of Cohort Studies in the Context of Cancer Hazard Identification

Objective

We performed a meta-analysis of epidemiological results for the association between occupational exposure as a firefighter and cancer as part of the broader evidence synthesis work of the IARCMonographs program.

Methods

A systematic literature search was conducted to identify cohort studies of firefighters followed for cancer incidence and mortality. Studies were evaluated for the influence of key biases on results. Random-effects meta-analysis models were used to estimate the association between ever-employment and duration of employment as a firefighter and risk of 12 selected cancers. The impact of bias was explored in sensitivity analyses.

Results

Among the 16 included cancer incidence studies, the estimated meta-rate ratio, 95% confidence interval (CI), and heterogeneity statistic (I2) for ever-employment as a career firefighter compared mostly to general populations were 1.58 (1.14-2.20, 8%) for mesothelioma, 1.16 (1.08-1.26, 0%) for bladder cancer, 1.21 (1.12-1.32, 81%) for prostate cancer, 1.37 (1.03-1.82, 56%) for testicular cancer, 1.19 (1.07-1.32, 37%) for colon cancer, 1.36 (1.15-1.62, 83%) for melanoma, 1.12 (1.01-1.25, 0%) for non-Hodgkin lymphoma, 1.28 (1.02-1.61, 40%) for thyroid cancer, and 1.09 (0.92-1.29, 55%) for kidney cancer. Ever-employment as a firefighter was not positively associated with lung, nervous system, or stomach cancer. Results for mesothelioma and bladder cancer exhibited low heterogeneity and were largely robust across sensitivity analyses.

Conclusions

There is epidemiological evidence to support a causal relationship between occupational exposure as a firefighter and certain cancers. Challenges persist in the body of evidence related to the quality of exposure assessment, confounding, and medical surveillance bias.

All-cause and cause-specific mortality in a cohort of WTC-exposed and non-WTC-exposed firefighters

OBJECTIVE

To compare mortality rates in World Trade Center (WTC)-exposed Fire Department of the City of New York (FDNY) firefighters with rates in similarly healthy, non-WTC-exposed/non-FDNY firefighters, and compare mortality in each firefighter cohort with the general population.

METHODS

10 786 male WTC-exposed FDNY firefighters and 8813 male non-WTC-exposed firefighters from other urban fire departments who were employed on 11 September 2001 were included in the analyses. Only WTC-exposed firefighters received health monitoring via the WTC Health Programme (WTCHP). Follow-up began 11 September 2001 and ended at the earlier of death date or 31 December 2016. Death data were obtained from the National Death Index and demographics from the fire departments. We estimated standardised mortality ratios (SMRs) in each firefighter cohort versus US males using demographic-specific US mortality rates. Poisson regression models estimated relative rates (RRs) of all-cause and cause-specific mortality in WTC-exposed versus non-WTC-exposed firefighters, controlling for age and race.

RESULTS

Between 11 September 2001 and 31 December 2016, there were 261 deaths among WTC-exposed firefighters and 605 among non-WTC-exposed. Both cohorts had reduced all-cause mortality compared with US males (SMR (95% CI)=0.30 (0.26 to 0.34) and 0.60 (0.55 to 0.65) in WTC-exposed and non-WTC-exposed, respectively). WTC-exposed firefighters also had lower rates of all-cause mortality (RR=0.54, 95% CI=0.49 to 0.59) and cancer-specific, cardiovascular-specific and respiratory disease-specific mortality compared with non-WTC-exposed firefighters.

CONCLUSION

Both firefighter cohorts had lower than expected all-cause mortality. Fifteen years post 11 September 2001, mortality was lower in WTC-exposed versus non-WTC-exposed firefighters. Lower mortality in the WTC-exposed suggests not just a healthy worker effect, but additional factors such as greater access to free health monitoring and treatment that they receive via the WTCHP.

Development of a Manual for Disaster Medical Support Using Korean Medicine for Disaster Survivors

Objective: Disasters adversely affect the mental health of disaster survivors, leading to depression, anxiety, and stress-related disorders. Survivors complain of not only psychological symptoms but also physical symptoms such as insomnia, pain, and fatigue. Providing immediate and effective psychological support to all survivors is difficult because human and physical medical resources are limited. Therefore, the authors developed a manual for disaster medical support using Korean medicine (KM) for disaster survivors to provide prompt, effective, and long-term support that supplement existing psychological support. Methods: In this article, the authors introduce KM treatment protocols, which are unique elements of the manual. In addition, the authors have developed a step-by-step treatment protocol based on the stage and condition of survivors, as well as separate treatment protocols for psychological and physical symptoms. Results: The interventions include ear acupuncture, acupuncture, herbal medicine, breathing relaxation, stabilization techniques, emotional freedom technique, and self-care methods such as acupressure, exercise, and walking meditation. This manual has been certified as an official procedure of the Korean Society of Oriental Neuropsychiatry. Conclusions: The authors believe that this manual will enable KM doctors to be effectively utilized as medical resources at disaster sites. Furthermore, this manual would provide a good model that can be extended to countries that wish to use integrative medicine for disaster support to implement the commitments of the Declaration of Astana.

A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers

INTRODUCTION

Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up.

MATERIALS AND METHODS

We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk.

RESULTS

There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members.

CONCLUSIONS

We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

Tracking diseases related to the terrorist attacks of September 11, 2001

Accurate, timely, and complete disease reporting is essential to understanding the extent and long-term consequences of diseases related to the terrorist attacks of September 11, 2001 (9/11). Although there are no public health disease reporting requirements that specifically mention 9/11, other mechanisms exist to track 9/11-related illnesses. These include the availability of 9/11-exposed cohorts, some open to new member recruitment and others closed. Record linkages of 9/11 cohorts to various data registries (eg statewide cancer registries and the National Death Index) are periodically performed. This paper describes these 9/11 cohorts and the efforts to track their health experience.

Health effects following exposure to dust from the World Trade Center disaster: An update

Exposure to dust, smoke, and fumes containing volatile chemicals and particulate matter (PM) from the World Trade Center (WTC) towers' collapse impacted thousands of citizens and first responders (FR; firefighters, medicals staff, police officers) of New York City. Surviving FR and recovery workers are increasingly prone to age-related diseases that their prior WTC dust exposures might expedite or make worse. This review provides an overview of published WTC studies concerning FR/recovery workers' exposure and causal mechanisms of age-related disease susceptibility, specifically those involving the cardiopulmonary and neurological systems. This review also highlights the recent findings of the major health effects of cardiovascular, pulmonary, and neurological health sequelae from WTC dust exposure. To better treat those that risked their lives during and after the disaster of September 11, 2001, the deleterious mechanisms that WTC dust exposure exerted and continue to exert on the heart, lungs, and brain of FR must be better understood.

Application of Standardized Proportional Mortality Ratio to the Assessment of Health Risk in Relatively Healthy Populations: Using a Study of Cancer Risk in Telecommunication Workers with Excess Exposure to Acid Mists as an Example

When a study population is relatively healthy, such as an occupational population, epidemiological studies are likely to underestimate risk. We used a case study on the cancer risk of workers with exposure to acid mists, a well-documented carcinogen, to demonstrate that using proportional mortality ratios (PMRs) is more appropriate than mortality ratios in assessing risk in terms of mortality. The study included 10,229 employees of a telecommunication company who worked in buildings with battery rooms. In these buildings, the battery rooms had the highest levels of sulfuric acid in the air (geometric mean = 10.7 μg/m3). With the general population in Taiwan as a reference, a decreased standardized mortality ratio (0.42, p < 0.01) from all causes combined, between 1 January 1985 and 31 December 1996, was observed, indicating a healthy worker effect. When we reanalyzed the data using standardized PMR, elevated risks were observed for all cancers combined (1.46, p = 0.01) and cancers of the digestive organs and peritoneum (1.61, p = 0.02), especially stomach cancer (2.94, p = 0.01). The results showed that PMR can detect increases in mortality when a study population is generally healthier than the comparison population and call for further studies on the possible carcinogenic effects of low-level acid mist exposures on the stomach.