THE HEALTH AND ENVIRONMENTAL CONSEQUENCES OF SEPTEMBER 11. Philip J. Landrigan, MD, MSc Icahn School of Medicine at Mount Sinai

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1 THE HEALTH AND ENVIRONMENTAL CONSEQUENCES OF SEPTEMBER 11 Philip J. Landrigan, MD, MSc Icahn School of Medicine at Mount Sinai

2 The attacks on the World Trade Center produced the greatest acute environmental health disaster that ever has befallen New York City

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7 Dust and smoke from the fires

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10 Dust from materials transfer 42

11 Releases Night and Day

12 The Medical and Public Health Response to 9/11

13 Mount Sinai s Response to 9/11 Builds on the Legacy of Dr. Irving Selikoff Professor Irving J. Selikoff, M.D The Father of Occupational Medicine in the United States

14 The Public Health Response to 9/11: Three Phases Phase I: Immediate aftermath

15 Phase 1. Tens of thousands of rescue workers and volunteers rushed in to help

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17 An estimated 400,000 local workers and residents were in the area

18 Over the weeks after 9/11, controversies began to mount over the potential health effects of the disaster

19 Controversy developed While few argued that there might be substantial health consequences from the disaster, there was substantial disagreement over the nature and risk of exposure to airborne contaminants In a press release and in statements to the media on September 18, 2001, EPA announced that the air was safe to breathe But many public health experts and clinicians on the front lines were seeing evidence that the air was not as safe as claimed This was when epidemiology and environmental science began to make essential contributions

20 To resolve this controversy, medical and public health teams began working to identify: What were the exposures? Who was exposed? How could hazardous exposures be prevented? What were the health effects? To workers and volunteers involved in rescue, recovery, and restoration of essential services To local workers, many of whom evacuated but returned to work soon after the disaster To community residents These questions were addressed in phases 2 and 3

21 Phase II. Assessment of Environmental Exposures

22 Components of Exposure Assessment High-altitude imaging of the atmospheric plume Meteorological modeling of the plume Chemical analyses of settled dust Indoor sampling of buildings near Ground Zero Ambient air sampling

23 WTC Plume September 11 and 12, /12 9/11 Chillrud, Small et al

24 WTC Plume Aviris imagery, September 16, 2001 Visible Color Visible Blue Near IR Chillrud, Small et al

25 Sampling of Exterior Settled Dust near Ground Zero Goals: 1. To determine the chemical and physical characteristics of material in the initial plume. 2. To assess potential acute or chronic effects on human health.

26 Collecting Settled Dust Samples Lioy, et al, 2002, Sampling at Cortlandt St.

27 Components of Settled Dust from the WTC Chrysotile Asbestos ( %) - used in construction of North Tower to 40 th story Cement dust (ph ) Glass fibers Lead and other Heavy Metals Polychlorinated biphenyls (PCBs) Toxic Products of Combustion 1. Benzene and other VOCs 2. Polycyclic Aromatic Hydrocarbons (PAHs) 3. Dioxins 4. Diesel fumes 5. Sulfur dioxide

28 General Appearance of Bulk Dust Collected at the Cortlandt, Cherry, and Market Street Locations East of the World Trade Center Lioy et al, 2002

29 Chrysotile Asbestos in Market Street Dust Sample Lioy et al, 2002 Millette, MVA micrograph

30 Indoor Dust Sampling Lioy et al, 2002, Sampling Indoors

31 Indoor Deposition of Dust and Smoke Lioy et al, 2002

32 Chrysotile Asbestos in an Indoor Sample Lioy et al, 2003, Millette, MVA Micrograph

33 Ambient Air Sampling near Ground Zero Goals: To measure time trends in airborne contaminant levels To build a composite picture of the geographic pattern and components of low altitude airborne contamination

34 Principal airborne toxins in lower Manhattan after 9/11 Silica Pulverized Cement and Gypsum (ph 10-11) Asbestos Glass Heavy Metals Soot VOC s Acid Mists Organic Products of Combustion (PAH s etc)

35 Mean airborne concentration of PAHs at Ground Zero and at 290 E. Broadway, Manhattan, New York

36 Summary Time Course of Environmental Exposures Following the Attack on the World Trade Center Four Periods (Lioy et al. 2002) Time Period Period 1 First 12 hours post collapse (September 11, 2001) Period 2 Day 1 evening through Day 2 Period 3 Day 3 through Day 13 Period 4 Day 14 through December 20, 2001 Predominant Sources of Pollution Burning jet fuel Fires Collapse of the Twin Towers Burning jet fuel Re-suspension of settled dust/smoke Smoldering fires Re-suspension of settled dust/smoke Smoldering fires with occasional flare-ups Removal of debris by trucks and other heavy equipment Airborne Pollutants 1. Combustion products gaseous and particulate 2. Evaporating gases from the collapse of the Towers 3. Coarse particles 1. Combustion products gaseous and particulate 2. Gases evaporating from piles 3. Re-suspended coarse particles 1. Combustion products gaseous and particulate 2. Coarse particle resuspension 3. Diesel exhaust 1. Combustion products gaseous and particulate 2. Diesel exhaust

37 Phase III. Assessment of Health Effects in Exposed Populations

38 Deaths at the World Trade Center 2,726 total 343 firefighters 60 police officers Residents of 26 states Residents of 8 foreign nations 77% males; 23% females Median age, 39 yrs (range 3-85 yrs)

39 Populations at Greatest Risk of Toxic Exposures and in Need of Medical Follow-Up First responders Firefighters, EMTs, Police, Volunteers Other workers and volunteers in and near Ground Zero - Construction Workers, Transit Workers, Cleaners Office workers in Financial District Residents of lower Manhattan, especially children Pregnant Women

40 World Trade Center Cough Defined as persistent cough that developed after September 11 and lasted at least 4 weeks Apparently caused by intense airways irritation resulting from inhalation of alkaline cement dust (ph= ) and glass fibers

41 WTC Cough in Firefighters Prezant et al. 2002

42 Respiratory Symptoms in Ironworkers (n=97), Autumn, 2001 Upper airway disorders Lower Airway Disorders Rhinitis Sinusitis Pharyngitis Laryngitis Asthma Chronic dry cough Aggravation of pre-existing lung disease Pneumonia Effects most common and severe in earliest arrivers

43 Psychological and Socioeconomic Consequences in Ironworkers Autumn, 2001 Psychological effects PTSD Anxiety Depression Social and economic consequences Loss of employment Impact of families Increase in substance/alcohol use

44 Based on Mount Sinai s and FDNY s Initial Clinical Findings, Need Became Clear for Larger Scale Clinical Programs

45 The WTC Worker and Volunteer Screening Program ( ) A screening program that began at Mount Sinai in July 2002 with federal funding through NIOSH Goal: To rapidly provide free standardized screening exams to all WTC responders Examination purposes: To identify current WTC-related physical and mental health problems To serve as baseline for future exams Parallel program at FDNY Federal funds covered diagnosis, but not treatment

46 The Mount Sinai World Trade Center Worker and Volunteer Medical Screening Program Examinations included: Standardized medical and exposure interviews Mental health assessment Chest x-ray Spirometry (pre and post bronchodilator) CBC, blood chemistries, UA

47 WTC Medical Screening Program 5-Year Findings High rates of persistent symptoms: 50% had WTC-related lower airway symptoms Spirometry : 33% abnormal Mental Health: 12.9% met criteria for PTSD These findings made clear the need for ongoing monitoring beyond one-time screening MMWR, September 10,2004

48 Further Evolution of the WTC Medical Program In 2006, on the five-year anniversary of9/11, we published a major article in Environmental Health Perspectives documenting persistent symptoms in a high proportion of previously healthy first responders. These data stimulated the Congress to provide funding for medical treatment of responders But unfortunately funding was year-to-year, one year at a time, which created great uncertainties. Finally in 2011, Congress passed the James Zadroga 9/11 legislation, which established stable, multi-year funding

49 Unsung Hero of 9/11 Jon Stewart

50 Sinai WTC Medical Program Current Status Federally funded through NIOSH supported under the Zadroga Act since July 1, 2011 Provides baseline and follow-up physical and mental health exams for all eligible responders 30,000 responders have received a baseline examination through the program 14,000 responders have received a follow up examination 20,000 of these responders are followed at Mount Sinai

51 Cumulative Incidence of Physical Health Problems at 9 Years Asthma 27.6% Chronic Sinusitis 42.3% Gastroesophageal Reflux Disease (GERD) 39.3% Spirometric Abnormalities 41.8% (3/4 are restrictive) Rates of All Conditions are Highest in Most Heavily Exposed

52 Figure 4 Co-Morbidity of Physical Conditions in 9/11 Responders Source: The Lancet 2011; 378: (DOI: /S (11)61180-X)

53 Figure 3 Cumulative Incidence of Abnormal Spirometry in 9/11 Responders Highest Rates in Most Heavily Exposed Source: The Lancet 2011; 378: (DOI: /S (11)61180-X)

54 Mental Health Findings Mental health conditions as common as physical health conditions PTSD was widespread immediately after 9/11, but resolved within 6 months for many Cumulative incidence (%) at 9 years: NYPD Other Depression PTSD Panic Disorder All rates highest in most heavily exposed

55 Figure 5 Co-Morbidity of Mental Health Conditions in 9/11 Responders Source: The Lancet 2011; 378: (DOI: /S (11)61180-X)

56 What we Don t Know Full impact of WTC exposure on late health effects including: ocancer o Pulmonary fibrosis and other lung diseases o Autoimmune diseases o Other? Persistence of physical and mental health conditions

57 Conclusions Respiratory, gastrointestinal and psychological symptoms are prevalent, severe and persistent in WTC responders. Respiratory effects are most likely due to inhalation of alkaline dust. New diseases may emerge in future years Assured long-term, federally supported follow-up will be essential to deal with persistent and delayed effects in these heroic men and women lung disease, mental health problems, and possible cancers.

58 Final Thought None of this response would have been possible without the wisdom and forethought that established Centers of Excellence in Occupational Medicine at Mount Sinai and across New York State more than a decade before 9/11

59 Thank you