Hi, good morning, everyone. Welcome to the World Trade Center Health Program talk today. I'm Jackie Moline. I'm the Senior Vice President and Professor of Occupational Medicine, Epidemiology and Prevention at Northwell Health and the Zucker School of Medicine at Hofstra-Northwell. And with me today is Iris Udison, who's a Professor of Environmental and Occupational Medicine at Rutgers. And the two of us will be tag-teaming this presentation today. Housekeeping, please silence your cell phones. Evaluate and claim credit by navigating in the event app and the neon green link at the bottom left at the end of each session. Download the event app if you haven't, which would allow you to get your CME. If you need assistance, visit the registration desk or the membership booth. And also look for the red lanyards, who are your help. So just to give you a little introduction to who we are and why we're here. We are both directors of clinical centers that make up the centers in the New York metropolitan area. There are five or seven centers located at the Fire Department of New York, at Northwell, at Rutgers, at Mount Sinai, at Stony Brook, and at NYU. There is a survivors program. Survivors are anyone who lived or worked in the area but did not work in the pile or at the site known as Ground Zero. And then there's also a national program, which is really why we wanted to speak to you today for those of you who are outside of the New York metropolitan area. You may have the opportunity to see patients, so we wanted to give you some understanding. We have no disclosures. I'm going to show you a few pictures. The pictures are not for shock purposes. The pictures are to, and they may be disturbing to some folks, so I just want to give you a warning. There are about six pictures. Some of them are credited to Getty, but some of these are iconic pictures. I want to give you an understanding of what the dust cloud means, when you hear us reference it later, and just what people look like as they are walking through. So this is the dust cloud after the towers fell. This is what you can see, the dust cloud you can see in the picture on the bottom right. You can see how high the dust rose, and the firefighter covered. Now this is an iconic picture of a woman who actually has subsequently passed away. This was taken by photographer for Getty. That picture, I don't know its providence, but if you take a look, you can see the yellow dot there, that's actually a light. You can see how thick the air was. I have other pictures, I didn't put them in, but I call it one day turned to night, because it was so dark that it looked like it was nighttime. So what made up the dust? We know there was asbestos 2 to 4%, hydrochloric acid, PCBs, silica, heavy metals, PAHs from the fires, dioxins, and about 150 different compounds. Just to give you a little historical reference, this is what they looked like in 1999. This is when the first tower was hit at 845, and then this is after the collapse. So there were about half a million people exposed to dust, debris, smoke, and other carcinogens. There were physical and psychological stressors, and there will be, as we'll get into it, a risk of a variety of cancers. Individual exposure was determined by duration and intensity of the exposure, as well as the use of protective equipment. New York City, lower Manhattan, in September 2001 had the most protected necks in the world. Everyone wore their masks around their neck, if they had one, meaning they weren't wearing them appropriately. It was like the new necklace. It was one of the biggest public health PPE disasters, probably only worsened with COVID, in terms of the limited availability, and more importantly, the limited usage of PPE. The World Trade Center Health Program was created to address some of the various illnesses, but initially it was developed to understand what had happened to folks. I did not have World Trade Center dust exposure, but what was in the dust? Paul Loy, who was one of Dr. Udison's colleagues at Rutgers, on September 12th and 13th went and collected dust. We owe him a debt of gratitude, because through his astute collection, we understand what was in the dust, and these are some of the samples he obtained, which showed there was pulverized concrete, glass, metal, and asbestos. It was highly alkaline. The alkalinity is important to know, because it's far more caustic than acid, and many of the findings we have are probably related to the pH, or the high pH. Most of it was greater than PM10, about 90% was greater than PM10. Thank you so much. However, some of the estimates were that it was over 100,000 milligrams per cubic meter, so it overwhelmed any defense mechanism, which is normally around 10 millimeters, so people had tons of dust they were breathing in, just because of the sheer magnitude of the exposure. There was a long deposition of large particles. We see this from studies that were done of bronchoscopy among folks. They could find large amounts of fiber, and they even found it 10 months later in an individual. Only about 20% of folks wore masks the first day, and 90% of FDNY responders had acute respiratory symptoms within 48 hours. There were no actual measurements of what was in the air for about two weeks. There was dust samples, but we don't know what was in the air, so we've had to use proxies. It's one of the shortcomings, but this is, you deal with the data you have. So we know that there was, for those folks who had early arrival, if you were there and in the dust clouds that I showed you, that's one of the highest risk factors. The magnitude of exposure, more than 90 days, delay in mask and respirator use, which actually is almost everyone, and what the workers' roles were. Were they directly on the pile? Were they working on the barges? Were they more in the cleanup phase? And there was also the element of the survivors who were displaced, how long were they out of their homes? So a very quick timeline, 9-11, the towers hit, Tower 7, the forgotten tower, a 50-story building collapsed at 5 p.m. on 9-11. No one died, thankfully, in that building because it was evacuated, but it did add more dust and more dust cloud later in the day for subsequent exposures. So it was basically 270 floors of building collapsed. September 14th, it rained, it rained horribly, and what it did is it cleared the air. So that's often the demarcation between the heaviest exposed and the lesser exposed. The infamous air is safe to breathe came on September 16th, which allowed for the stock market to open on September 17th. On April 15th, 2002, we got one year of funding for medical surveillance, the fire department had one, and then the responders who were the police, the non-fire department of New York firefighters, and all other construction workers, volunteers, psychologists who came down to the site. We received initially 9 million, we're supposed to recruit 6,000. We stood up the clinic in three months, there's a much younger me examining a patient, and then we opened satellite clinics in December of 2002, and then eventually we got funding for a second year. We had to see 12,000 folks, we saw 11,982. So we did pretty good in terms of our recruitment, and then the program's continued. A bill introduced for continued funding failed, but then we got more money, and then the fifth anniversary, they decided to fund all the programs and also give us money to start treatment. Initially we could only diagnose, we couldn't treat, unbelievably frustrating as a doctor to be able to say, you have this, this, and this, sorry, we can't pay for it. 2009, there's the Droga Act, which is named after a police officer who died of World Trade Center-related lung disease. It passed in very late December 2010, and it was signed into law January 2011. So it established the World Trade Center Health Program at that point, and it didn't cover cancer until the next year, like about 16 months later, but it was only five years. So then the reauthorization push came through, and it continued in 2014. It ended in 2015, but it was reauthorized in 2015, it did December 2015 for 75 years, which is basically unheard of for a federal program. The Victim's Compensation Fund came for five years. John Stewart brought back the first responders to the show that he had in 2010, which is when he was pushing for it. Only three of the six were still alive. Through his efforts, as well as the advocacy of a number of groups, unions, responders, our political allies, the program was reauthorized. And then we had another push in 2019 to reauthorize the Victim Compensation Fund, which was established to compensate folks if they develop serious medical illnesses. So what is the World Trade Center Health Program? It's a medical surveillance program at eight clinical centers for New York residents or New Jersey residents, or Connecticut, and there's a national program which cares for members who live outside the metro area. It works as a third-party contract under the health program. There's medical and mental health services, and folks with training for referrals if you have pulmonary issues, or ENT, or GI, or cancer. And the cohorts are open to join any time if they meet the eligibility criteria. If they're eligible, it's determined by NIOSH, the National Institute for Occupational Safety and Health. Here's a list of the services, which are annual examinations for monitoring, treatment, and referral for World Trade Center-related conditions, which Dr. Udison will go into the nonmalignant conditions, cancer screening, benefits, research. There's a huge research program. People who are eligible are people who lived below Canal Street, and then in parts of Brooklyn, the community residents. There's also allied programs for those exposed to the Pentagon and Shanksville, and so it's basically people who lived or worked in the area. You can see the enrollment over time with the two groups, and the overall, the red line is the responders, the blue line is the survivors, and again, the survivors are people who lived or worked in the building. Let's say you worked on Wall Street, and you were there on 9-11, and then you went back the next week. You're considered a survivor. That's just the terminology. The new enrollees, and you can see it peaks. It tends to peak on the five-year marks. Again, you can see the numbers of new enrollees. This is in the past 24 months, so people are still enrolling. We get about 800 folks a month enrolling. You're saying, who are these people? Why are they coming in? If you're a survivor, you can only get in the program once you're ill. If you're a responder, you come in whether you're sick or not. If you were down there, then you can come in for annual monitoring. I can't tell you how many patients I've had, and I'm sure Dr. Udison has had, who don't come in for like 15 years until they become sick, because they're like, save the money for someone else. It's people I work with. I work with a lot of former cops who do the security or our health system, and I'm like, are you in the program? They're like, no, I don't need it. I don't need it. They're all in the program now because they need it. That's just the new enrollees in the past 24 months. This is where people came from, every state. There's two reasons why people are in every state now. One, there was a huge nationwide rescue and recovery effort, so people came who had skills or maybe were contracted to come, and then they went back to their communities, and then people have retired or moved away from New York. There are certain states that have more folks based on size or based on, those are frequent retirement like the Carolinas and Florida, had more people. Cancer, which has now been covered for about 12 years, there's a number of studies have all concluded that there's a link between exposure and melanoma, prostate, thyroid, and other cancers such as lymphoma and multiple myeloma. We align with the USPFTF, the United States Preventive Services Task Force, which includes medical surveillance for any type, group A or B cancer recommendations, and I'll show that on the next slide. It assumes that assuming the criteria for exposure and minimum latency are met, and I'll show you those numbers in a sec, then all the care is covered. And the most common cancer is non-melanoma skin cancer, although melanoma is increased. So here's just the screening list to remind you, which is out of date, because now they've just lowered the breast cancer screening to 40 years for women. So this is what's recommended or what is allowed under the USPFTF. Ironically, that one of the highest rates of cancer is prostate. We can't do PSA, but if you come in with elevated PSA, we can treat you. It's just the vagaries of it's a level C recommendation currently from the USPFTF, so we can't cover screening. Not everything seems to make a lot of medical sense with the program, but it's the government at work. So the latency, here's the definition of latency, onset of exposure to development of disease. You have to have a minimum latency. And these are the official latency periods. And you can see that solid tumors are four years, mesothelioma is the exception at 11. Any of the blood cancers are 0.4 years, thyroid cancer is two and a half years, and childhood cancers are one year. All the kids who are in school or in the neighborhood and were young children then are covered. That is why it's a 75-year program, figuring that by 2090, people will have been, the youngest will be 79. So here's all the certified conditions and I'm going to, I have a couple more slides and then I'm going to turn it over to Dr. Udison to talk about some of the most common non-malignant covered condition. And as you can see, rhinosinusitis is up there, cancer is second, GERD is third, asthma and sleep apnea. We're going to hear a lot about that. And then the top 10 cancers are, this is in the responders, skin, prostate, lymphoma, melanoma, kidney, thyroid, and rare cancers, basically everything is covered. It doesn't matter the intensity. If you can, if you're accepted into the program, your cancer is covered. All of them underwent a review, a scientific review for plausibility. And in fact, the last cancer to be added was uterine cancer. So basically every cancer was covered until uterine cancer. And the majority of the clinical centers are headed by women. So all the female clinical center directors wrote a letter, spearheaded by Dr. Udison to say, can we cover this? Part of the reason it wasn't initially covered, in all fairness to the deciders, was that 80%, 86% of the responder cohort is male. So there weren't a lot of women who had the opportunity to develop uterine cancer. The survivor program, on the other hand, is basically 50-50 gender neutral. And so over time, there was enough data amassed for us to say these numbers are higher than would be expected in the population. And at that point, it got approved, and then it took another two years for it to go through the federal register and all the rulemaking processes. But it is now covered. So in the survivor, you can see, because of the gender mix, that it's prostate, non-melanoma skin, breast, lymphoma, thyroid, lung, kidney, leukemia. What I'd love to talk about what the pathology is, or pathophysiology is, and why we think they're elevated, but we don't have enough time. So I'm going to turn it over to Dr. Udison to talk about non-malignant health conditions, and then I'll come back and we'll talk about some of the mental health and wrap it up. So thank you for coming to listen to us. I have the great pleasure of being able to do the surveillance and the treatment. So for those of us who do surveillance, and you write that letter saying, we found this, that, and the other thing, and the purpose of my talk is to tell you which things I think you can be treating, and which things we need to refer. And again, with great pleasure, I'm going to go on. Which one advances? Right here. Okay. Good. So why do we care so much about the sinuses? And Dr. Moline is very modest. There was a picture of her, and she was being diagnosed with sinus problems by one of our leading ENT. She didn't show that picture here, but we all go back a really long time, and standardizing this. So when we talk about sinuses in the world trade population, I want to hearken back to the picture that Jackie showed with all those dust clouds, and we're not talking about sinus problems that started in 2020. We're talking about sinus problems that started in 2001. Maybe people didn't bother to get treated because they were too busy doing service to worry about their sinuses, but these are people with chronic problems. And you can see that the World Trade Center patients have more than twice the level of sinus problems compared to the general population, and without a lot of ATP. The next bullet here is something that's important to think about in our population, which is the continuum of inflammatory findings, and of course, inflammatory findings lead to other problems, and we'll be speaking about this. The other thing in the course of World Trade Center is we found every standardized guideline for every treatment that's been published by every federal organization. So consensus on allergy and rhinology, rhinosinusitis. So having said that, how do we make the diagnosis? Major symptoms, rhinorrhea, et cetera, minor symptoms, headache, cough is going to come up on everything we do, everything. And I'm also pointing out the dental issues, because they turn out to be a lot more important than we originally thought, but why is it really important? It's really important. Our studies, other people's studies have shown that these sinus problems can be potentially really debilitating, and they shouldn't be ignored. And this is something we can all treat in our practices when, if you're the doctor and the nurse practitioner in Oregon that's seeing my patients, or Oklahoma, please treat them because they're having problems doing social, physical, emotional functioning. We've been able to show cognitive issues. Certainly those of us who are concerned about absenteeism, and of course all this sinus stuff is a risk factor in the development of asthma. We all know that for various exposures that we've evaluated, that the sinuses, the eye problems, all that leads to asthma. So this is a slide for everybody to memorize here, really busy. But what I want to highlight in this slide without a pointer is the beauty, oh, I have a pointer. Oh, good. Hey. I think it's the top one, the top. Let's try it. Let's see. Oh, no, no, no, oh, this is the thing that makes it go ahead. Okay, let's see. Let's forget about the pointer, because I'll mess that up. So what I want to point out is nasal saline irrigation is a really, really easy thing to do. You don't have to go and get the dreaded neti pot. You can go into your pharmacy or Amazon and order really nice pre-prepared nasal saline rinses. They really do work. They may even work as well as the nasal steroids. These are the other things that we as octocs and primary care people can do are short-term antihistamines, maybe decongestants, maybe leukotriene modifiers like Montelukast. So these are the things that we can do in our practices that make life easier for our patients. And when do we have to refer? When do we have to refer? We have to refer when there are alarm systems, lots of bleeding noses, ocular symptoms, severe facial pain, headaches where maybe there's a neurologic event going on. People think they have sinus problems and maybe they're having some other things. So we do send them to neurologists, asthma issues, and my beloved subject, sleep apnea that's going to be talked about more than Dr. Moline wants me to. So in any event, gastroesophageal reflux. So people don't necessarily think about that as an occupational illness, but this is one of the largest things that we've seen in the World Trade Center program. And just thinking about all those alkaline things that people inhaled at the World Trade. So you'll just think about that. And in our GERD, some anatomic slides. But so now the symptomatology, sometimes you're lucky with GERD and they actually have dyspepsia and heartburn, but most of the time you're not lucky with GERD. And for those of you who've seen me all week at this meeting, I do know my GERD triggers, but most people don't. And another problem for us in World Trade and probably in a lot of people's practices is the concept of laryngeal pharyngeal reflux, meaning the patient presents with a sore throat. And that sore throat doesn't go away and we sent them to ENT and ENT finally takes a look and says, you know, I don't like the looks of his oropharynx and I think it's probably more likely GERD. So in any case, not always an easy diagnosis to make. And a number of us participated in a review process. But look at the way GERD interacts with other things that we keep talking about. Psychologic stress and post-traumatic stress. And whether it's World Trade Center or not, GERD correlates very well with mental health and it's chicken and the egg. So what can we do in the primary care setting? We can do the best we can to make a diagnosis. There's no reason why we can't give the PPI right in the initial office. You don't need to refer all over the world for that. And for the most part, that's the biggest diagnostic tool is the response to the PPI. Give them the omeprazole and see what happens. Obviously we need to refer for the diagnostic EGD, which we should do after we've seen a response to the PPI. Why should we do that? Because at least once in their lifetime, they need to be screened for Barrett's esophagus. So I want to say this about the GERD, which is if the GERD just started this year, it's probably not 9-11 related. We probably wanted it to have started at least within five years of either their 9-11 service or when they started having rhinosinusitis. But again, reflux that we just see in 2024 is unlikely to be related to world trade unless, of course, it's a complication of treatment of something else. Because of course, treatment of cancer, there's a lot of cancer treatments that can lead to GERD. So what can we do in our practices with respect to GERD is being really mindful of diet and lifestyle. One of the things that our program has afforded us is the nutritionist to help us. But certainly weight loss and alcohol are really important, avoiding late night meals. I think that most of our patients would rather, and maybe most of us, most of us would rather go for a test, go for a CAT scan of something or an MRI of something than actually change lifestyle. But we in this program are blessed that we have enough time to spend with people to talk about lifestyle. Certainly antacids and proton pump inhibitors are easier to use, and H2 blockers are something we can all do. Knowing that, of course, the PPIs have other side effects, we try to do what we can do even with the H2 antagonists. Obviously surgery is a last resort, but there are a lot of responses to some of the newer procedures. The TIF procedure is a very non-invasive way of treating intractable GERD, so it is certainly possible to treat this, so I call your attention to it. Asthma, what do I want to say about asthma in our limited time is we have certainly seen a lot of asthma. Most of our asthmas did present soon after 9-11 within the five-year period, but those are the asthmas that we knew how to diagnose. Remember that a lot of people with asthma have co-variant asthma, so we had to think about their asthma. Maybe it was even later than that and they had asthma all this time and they probably should have been treated. But in our program where we actually get to know the people, we do have the opportunity to do that. Come on, go away. The next slide just shows the increase in frequency, but this is a really good FDNY slide here. The New York Fire Department had data before 9-11 and after 9-11, and they were able to show that even in the healthiest firefighters that were out running and super-duper people, there was 372 mLs loss of FEV1 that could be seen. Come on. In any event, this is one of our best practices articles by our colleague at NYU, Dr. Harrison, and she outlined the heterogeneous presentation in more detail. This is included in the reference. The other thing to say is that while it was a toxic exposure, not everybody followed the recipes in the Brooks criteria. So again, we have asthma treatment guidelines here, which are very well documented in various publications. What can we do as the occupational doctors without the specialists? We certainly can start the short-acting beta agonists, the albuterol in our practices. Most of us in the World Trade Center program are certainly comfortable using the step-up therapy, the inhaled corticosteroids, the inhaled corticosteroids, LABA. I tend to start referring somewhere in the anti-muscarinics, and I'm certainly referring when I get up to the biologics, but the biologics are an absolute miracle because the biologics keep us from needing to use as many steroids, and we all know the complications of long-term steroid use, and unfortunately, we get to see a lot of that in the World Trade Center program. So my favorite discussion here is about sleep apnea, and I have included a lot of slides that are here for your reference, but one of the things that we were able to show my friend and colleague, Dr. Sundram, and I, we discovered that because of all this inflammation, because of all the ... We believe that we've really identified sleep apnea as an environmental and occupational illness. Now I'm speaking about this from the point of view of people doing World Trade exams, but clearly as a population of occupational physicians and nurses, treatment of sleep apnea is really important, and with an environmental exposure like this, with all the chronic inflammation, we were able to show that obesity was not the most important factor in identifying sleep apnea. And so this is a nice slide about anatomy. This is just a slide to show you when you go and look at a sleep study, that 3% and the 4% thing that's always confused me, but basically this is about how long people stop breathing for, and what the decrease in oxygen desaturation is. So this is actually an important slide because we know that if you have at least moderate sleep apnea, meaning at least 15 events per hour of sleep, we know that you're going to be in serious trouble and these are the people that we need to worry about treating. Here's what's also important. The next two slides are what's also important. The people with longstanding sleep apnea go on to develop a lot of other problems. Do we know if the sleep apnea caused the problem or not? We don't exactly know, but these are the things that we worry about because clearly not having enough oxygen affects us cardiovascularly. We have a study going on right now and we are looking at cognitive impairment in our people that snore, people that are identified with sleep apnea, and as you can see and as many of us know, increased motor vehicle accidents. Dr. Missinger presented in the resident discussion on Sunday afternoon about all the various things that people don't divulge on their commercial driver exams and clearly sleep apnea is one of the things people don't want to tell their doctors about. So what can the OCDoc do? The OCDoc can certainly order the screening tests for sleep apnea. If you're seeing my World Trade patients, you should assume they all have sleep apnea because at least 75% of them have some degree of sleep apnea. They don't all need to be treated, but an awful lot of them do. If the 9.7 plus the 19 are the people that definitely need to be treated and some of the mild people need to be treated, and I think that's pretty amazing how many people have it and what can we actually do? What can we actually do? We can do the, we can do, we can start the CPAP. We can start the CPAP. You can write an easy prescription for an auto titrating CPAP and you can certainly refer for oral appliances. The last things that I'm speaking about are things that do need the specialist. Luckily, we don't have a lot of COPD in our population. Luckily, not that many people fit the gold criteria of having FEV1 over FEC of less than 70% with no change with bronchodilators. Treatment, what can we do about it? We can do the smoking cessation, weight loss, decreasing hazardous exposures, but the rest of this we're going to be referring. Interstitial lung disease is the famous Zadroga illness. Again, this is something where we can be looking out for it, but we're going to be referring this. This is something we've seen starting with the New York City Fire Department, and you can see that there's an excess in sarcoidosis and interstitial lung disease compared to their usual baseline, and we were able to confirm that in the responder program. So again, what can we do? We can diagnose this horrible thing. We can treat this horrible, we can refer for treatment, calling your attention to using the high-res CT for this. The biggest thing that I do with the ILD patients is helping them with their workers' compensation. So I do a lot of time talking to our patients about should they work, should they not work, and I spend a lot of time with workers' compensation, and I'm really blessed that I get to be the good guy on the workers' compensation, not the bad guy. However, I do tell patients when they don't have a case, and it's clearly not World Trade-related. So turning this back to Jackie here on physical and mental health, they go together. They go together. Or we should just stop the demarcation of physical and mental health and just say health. One of the hallmarks of the World Trade Center program from its inception, and just to give a little historical, Dr. Udison and I have been involved from starting in 2000. For me, I got involved on September 12th, 2001, and have been working on it ever since. I think Dr. Udison started in 2002. October, looking at Jackie's nose. That's right, so we all got together and began developing the expansion of the program. Initially, it was just at Mount Sinai, New York, where I used to be. One of the hallmarks when we developed this program was we sat with our disaster psychiatry colleagues, and we said, we need to integrate this. We're dealing with folks that typically do not seek out mental health care. Police officers are afraid if they talk to a psychologist or a social worker that they will lose their gun. If they lose their gun, they lose their identity. So they don't go voluntarily. There are some amazing peer groups that are set up with cops that allow them to have some kind of peer support, or at least there were a lot of these peers. But we said, it's gonna be a station. Just like you're going for your breathing tests, you're going to see the social worker, and even if you don't think you have an issue, if you don't, that's great. If you do, we're gonna make sure you get the treatment. That's been a cornerstone of the program from the onset. So it's actually very interesting to see, and we've gotten a lot of people into treatment that would have never gone. So I want to give props out to Dr. Sandra Lowe, who's the director of the mental health program at Mount Sinai and chairs the mental health consortium for the World Trade Center. Many folks are still diagnosed with mental health problems because of their exposures. There's increased depression, and responders and survivors, and depressive disorders are associated with PTSD and substance abuse. There's increased rates of suicide as well. One of the unique aspects of the World Trade Center program has been that there are high rates of pulmonary symptoms with high rates of mental health abnormalities and anxiety. This actually, if you look at the body of literature that looks at coexistent mental and physical health, there is a significant correlation. Those with chronic medical conditions are more likely to have chronic mental health conditions. We see this in, dramatically with the pulmonary symptomatology. The working conditions were treacherous, chaotic. People were fearing for their safety for months. And they also kept seeing body parts. People still were just, I'm sorry to be graphic. People were finding body parts as late as May of March of 2002. So it wasn't just in the first few weeks, but it lasted for a very long time. It was a 16-acre disaster site. Psychological distress when there is disaster response is normal. Resilience is the most common. Exposure to disasters increases risk of subsequent diagnosis of psychiatric conditions. There is the increased risk of disease trajectory. So what did we have at this mass disaster? Environmental psychological hazards, immediate risk to life. Remember I told you after the initial fall, there was a second fall of another building which started all over again that same day. Community members were displaced and lost jobs. It was unsafe working conditions for many months. And most people, if they weren't a trained responder, which most of the people on the site were not, didn't have adequate training. There was a risk of medical and psychiatric conditions and the dual exposure influence in nature of the subsequent events. So here the program has stepped in and is covering all of these disorders with no cost monitoring and treatment. The most common diagnosed condition is PTSD or sub-threshold PTSD. Depressive disorders are also overwhelmingly common. 18.8% had major depression up to 15 years post 9-11. You know, a lot of the PTSD peaked around years two or three which is consistent with the literature. People often, and we're seeing that actually with physicians and burnout and COVID and with depression and PTSD and COVID. The first year burnout was actually dipped down significantly among doctors. And then it started peaking in around 2002 which is just exactly where you would expect it. We saw this in the World Trade Center as well. Substance abuse and trauma exposed populations. In general, people with PTSD have much higher rates of substance use disorder. With 9-11, we're seeing it about more binge drinking and PTSD and highly exposed responders. And there's elevated alcohol and drug related mortality. In 2019, data from the World Trade Center Registry which is a collection of folks that it's about 50,000 folks that followed, done waves of surveys. And this can be community residents, responders, fire department, anyone who had exposures. There's a treasure trove of data. And they found that the average number of 9-11 conditions in this cohort was about 2.7. And you can see the prevalence of the various diseases. What they found was depression was associated with a low health related quality of life and productivity. Nearly half had health, their health had limited their usual activities and 66% reported fair or poor health. Long-term determinants of depression, 18.6% depressed and about 26% had PTSD. If they had PTSD, they were more likely to be depressed. If they had low income, unemployment or low social support which is characteristic of PTSD in general. The burden of psychiatric disease, a number of papers have been written that show the comorbidity of physical and mental health disorders with comorbidity increased rates of GERD, increased rates of heart disease, increased rates of pulmonary problems. Asthma is more severe if there's coexisting PTSD and vice versa. Psychological, psychosocial consequences, family conflict, worker identity loss, unemployment, other factors associated with persistent illness depended on the severity, the characteristics of resilience, comorbidities, occupation and training. In the FDNY cohort, so the fire department cohort, 42% had one disease, 21% had physical and psychiatric, 7% had all three and comorbidity was most associated with chronic illness trajectory with the downstream psychosocial consequences contributing to morbidity. If you have physical disease, you have psychological disease as well. The two of them made things much worse. Some interesting findings from our work collectively has shown that PTSD prevalence differs. If you have previous training in disasters, your risk of PTSD is much lower. The nontraditional responders, the construction workers, engineers, volunteers, sanitation workers had no training in disaster work and they have the highest rates of PTSD. Suicidal ideation is increased in nontraditional responders versus the US population. Shows that prior training can protect and supports the importance of providing safety and training in all workers because you never know what's going to happen. Exacerbation has been noted following other disasters. War, there are a number of triggers. COVID-19 was a trigger for many folks. It was a pandemic, it was worldwide, it was life transformative for many industries, but there were also images that brought back. For those of us in New York, which is what the early epicenter of 9-11, constant sirens. Then there were also the visuals of the refrigerator trucks which evoked memories from 9-11. There's the anniversary reactions. So we've done a lot of research on resilience and protective factors and post-traumatic growth can occur in many individuals. It's an adaptive response to a traumatic event leading to positive psychological change. So it doesn't always mean that you're going to get PTSD. In some cases, people actually become stronger depending on their resilience, which can be self-efficacy is an important factor, social integration and having social support, that social support in so many different facets of our lives can be transformative. There've been studies looking at 20 years of health effects research. Doug Daniels from NIOSH published this that showed that direct exposure increases the risk of psychiatric disease. Prevalence varies, symptoms can arise many years later and endure for decades. And PTSD strongly predict functional impairment. They can be mediated by a number of different factors listed here. And the lessons learned from the World Trade Center Health Program is that there are meaningful actions we can take to reduce morbidity and diminish suffering. Prevention is key, training, ongoing screening and health monitoring of affected populations, monitoring both physical and mental health in parallel is paramount, facilitating access to care and financial and other barriers and offering collaborative care. One slide that we didn't put in there is probably the proudest slide or the proudest information. Studies have shown that if you are in the World Trade Center Health Program, FDNY responder survivor, actually they didn't include survivors, FDNY are responders. So annual monitoring treatment for World Trade Center related conditions. Your mortality is 27% less compared to those folks with World Trade Center exposures who are not in the program. So we're doing a good job. I think in large part, we also reduce another stress which is financial. The program covers everything. People also have care navigation. It could be a model of how we go in our health for healthcare in the US, but it definitely works. Dedicated professionals know what they're looking for. And that's in part why we wanted to talk to you today so that we could give you some guidance. There's a number of references here. There are a series of articles and this will all be in the packet. We gave these in time for them to be included in the packet. We published best practices, which includes much of what Dr. Utterson was talking about with respect to the non-malignant conditions in the archives of environmental and occupational health. This is a list of some of them, as well as there were actually 13 articles. And so we urge you to go to these. They can provide guidance of what to look for, what the standard guidelines are. For example, the gold guidelines are standard with COPD and asthma. It gives you the references for you to find them there. We want to dedicate this to all those affected by the disaster, the participating centers of excellence, and NIOSH. And these last few slides, these are more important to look at later, but this is from the national program. So for those of you outside the metro area who want to participate, the MCA Sedgwick is the NPN, the National Program Network provider, or the contractor. They use First Health and Prime. Here's the number to join. You can also go to the website. There's ways of submitting. Again, this will be, if you have the app, it's on the app. And this is the number to call for assistance. And this is the website for the World Trade Center. It's actually comprehensive. It has every article ever written about the World Trade Center. It has information about the programs, eligibility, how to enroll, how to get involved. Here's our emails if you have any questions. And we do want to encourage you to register for World Trade Center Health Program webinars. Again, you can probably find this on the website because it's a subset of the website, but it's cdc.gov slash WTC slash clinical care webinars. There are a series of webinars every two to four weeks. We urge you to take a look. And we want to thank you for your attention. And we have about five minutes for questions. Go ahead. Thank you so much for presenting in one hour this fast coverage. We're from New York. We talk fast. And we're very privileged to have two people who have been doing this for decades and with your perspective. And we really thank you very much. It's very well done. Thank you. I'm Michael Kosnett from Denver. And as a toxicologist, I was very intrigued by the panoply of cancers that seemed to be increased. I'm curious as to the magnitude of the increases, but I can look that up. I'm just wondering, you know, there is a sense now that we shouldn't necessarily view cancers by organ system in terms of differentiating them, but, you know, with increased understanding of the genomics of how many cancers probably are in different body tissues are formed by similar mechanisms that are more closely related. But can you, what are the, you know, we normally associate, you know, an alkaline dust exposure to like increase things like melanoma and some of these other types of cancers. So what, can you illuminate just briefly or point us in the direction of any literature or anything where we can learn about how this may have led to these different types of cancers? Sure. I think that we don't know a lot about the etiology. For something like melanoma, the PAHs are thought to be a risk factor for the melanoma and also the non-melanoma skin cancer. And actually, if you look to the firefighting literature, melanoma, the increase, it's a relative risk of about 2.3 for, I think it's somewhere around that. That might be the mesothelioma number, but it's somewhere around two. It's definitely elevated and it's probably thought to be the PAHs as well as all the gases. One of the challenges has been for the World Trade Center, and I think that may lead to why there's the more generous cancer coverage, is that we know there were gases and other substances beyond the dust. There was a lot of testing that was done at high atmospheric levels that found various compounds and no one knows how the combination of all this toxicity together may have increased the risks. But for melanoma and the skin cancers, it's thought to be the persistent... And some people were down there for like nine months, 10 months. So it wasn't just that they were there for two days. That may be one of the reasons. We are seeing a wide variety of different cancers, but they all have, I mean, obviously we're seeing a lot of adenocarcinoma, and is it that it's developing in different organs for different reasons? Or is there some compound that was in the dust that's acting on whatever the genetic susceptibility is in the genomic profile that's causing the various mutations? I think we're getting to a point where we're going to begin looking at the various signature, the genetic signature to see if there is a common pathway, because that's going to give us information that will help in the future with all cancers. And I don't think we're there yet. So I want to also add to that discussion, since Dr. Moline mentioned uterine cancer being added later, is we do have a little bit of a literature starting about endocrine disruptors and they were actually measured in the areas close to 9-11 schools. So while we personally, the two of us have been involved with the responder population, the survivor population includes children who are growing up in that area and they're no longer children anymore. So that's, as a toxicologist, you'd find that interesting. And the other interesting thing is the amount of shift work. Think about who our responder population were, police, firefighters, and the female responders that were there were largely law enforcement and largely working weird shifts. So let's say we've got the alkaline exposure, the endocrine disruptors, the shift work, the mental health, which is really bad for everything. The purans, the dioxins, all the other things. I want to also add, which is I'm going to be here all day. And if anybody wants to be thinking about setting up what they're doing in their clinics, I'm going to be hanging around things for police and firefighters so you can find me also. Thanks. Hi. Can you guys hear me okay? Yeah. My name is Dr. Lou Rock. Can you hear me all right? Yeah. Hi. Dr. Lou Rockowitz. I spent five years with Dr. Prezant at the FDNY World Trade Center Health Program. I sort of felt compelled to come here today. I just want to add one. I have to add one more thing. A lot of our female folks that were down there were with EMS. Right. Right. So please don't forget that. We wouldn't forget them. We don't. I just, I'm very passionate about that. You raise a good point. I mean, it's non-negotiable. I mean, it's traditional now, but we've been fighting for them. One question that I want, that I have, that I, from what I saw over my five years, and when you leave the program, you don't leave the program because you form very, you form forever bonds. And I actually just lost a guy a couple, like a couple days ago. Many of them followed me to Florida. But one question that I have, that I know there's no data on this, but you're a quintessential fireman. I'm, I'm being like, I got it, politically incorrect, but you're, most, most, most of my guys, my patients were men, but your quintessential fireman was a white guy. But what I observed was in Hispanic males and males of color that were at the World Trade Center, the pathology was disastrous. The, the, the, the severity of the aerodigestive conditions in Hispanic males were mind boggling. It knocked these guys offline. And you have a, you guys have a very different cohort from the cohort that I'm, that I have. And in many situations, I'm sending my, my guys to Dr. Lowe over at, over at Stony Brook. But is there anything that we're looking into so that we can learn for the future, when this happens again, when this happens again, what we can do to, to protect, protect the people that were forgotten from, from this program? So I'm interesting, and I'm sorry I didn't say EMS, being from, being from, being from New Jersey, the women that come to my office are, are generally law enforcement. But I think that outreach is one of the things that's most important to get the people in as early as possible. Because I, I think that if you're talking about Hispanic people, that maybe they didn't feel like a lot of the outreach efforts were in their language that they could understand. But whatever, whatever it is, getting people in as early as possible is really important. And trying to make the exams as comfortable for everyone, and, and having language interpreters when you're actually doing the exams, I think that's really important. Because we all know that we can use the language line, but the language line doesn't always get us the greatest histories. I'm, I'm not, that, that was- No, I, I get what you're saying. I think part of the issue is the fire department is not a good place to study this because it's like 99.3% white male. The responder cohort, on the other hand, is, and the survivor cohort, to a degree, is far more heterogeneous. I think we have about 25% non-Caucasian, I mean, if you have to think about who responded to the World Trade Center, it was often, in New York City, it's a very unionized construction. So they are, we have actually a huge Polish contingent who are the laborers, and there's a Latino component who are often the laborers. And then the NYPD is fairly heterogeneous, I mean, it's predominantly white, but it's changing actually over time. But I think a lot of the ethnic changes, or the multicultural changes happened after 2001. So, but we do have those, and we have shown that there are differences between ethnicities, just in certain, myeloma, for example, is more common in African Americans than in whites. And we've seen that, we've also seen, as you said, sarcoid, but I do agree with one of the things, is we're seeing folks who have crazy presentations of cancer. I mean, you know, we have a gentleman who's got rectal cancer that, unbelievably aggressive, metastasized to his brain, and just like, places that, I know colorectal can go to the brain. But, you know, it's just, we're seeing these very aggressive acting tumors that are just pretty devastating. I think I've approved about, so one of the things that the program does is we have to approve all the surgeries, all the treatments, all the various things. So it's like, we'll get incoming. If we don't see the patients, we know what's happening. I think in the past month, our cohort is, you know, it's not one of the largest programs, the centers. I have had three glioblastomas, I'm like, what is going on here? So we're seeing a lot of aggressive tumors, but thank you for your comments, and thank you for seeing our patients. Any other questions? Thank you for your work and the presentation. So I see patients in Maryland, so probably from that cohort of, not the responders, but the other folks. And just any tips you have, because a lot of them seem to be in care and have their primary care and up-to-date with their screenings, but I just want to make sure I'm not missing anything else that we need to do. So, I mean, there have been a number of fights to get federal workers included, and some of the more recent legislation did improve expansion for the Pentagon and the Shanksville site. I think the Shanksville site, for those folks who are there, is fairly limited just in geography, but the Pentagon folks could live in Maryland, certainly. I think it's making sure they're up-to-date on their cancer screening, like you said, just be on the lookout for the whole aerodigestive triad, the sinuses, asthma, GERD, interstitial lung disease, but just, I think, just doing what you're doing. I think, you know, we're seeing some early signatures. It's not covered yet. We've petitioned. We don't know if they're going to approve it. If we want to include another condition, there's a concern about autoimmune diseases and things like I published a case series with some folks at hospital for special surgery because they were seeing a number of patients with scleroderma, which is pretty unusual in men, but they saw a number of cases, so we're trying to do that. The fire department has seen a signature with some of the more unusual, very classic rheumatologic diseases beyond RA, you know, Sjogren's and dermatomyositis, and things that are just exceedingly rare in the population, but even more rare in younger men, so we're hoping that that will eventually be covered, but the one thing I do want to urge you is just be on alert for weird signals, so in 2007-2008, I happened to be seeing patients in the World Trade Center Clinic, and I saw, like, two guys who were late 30s with multiple myeloma. For any of you who did internal medicine, you know that's weird. You don't see 30-year-olds with multiple myeloma, so working with Dr. Uteson and some of my colleagues, we published a case series that found that the rates were increased in younger age, under 45, but it was a, this was in the early days. It was not so much, it's borne out to be the case that myeloma rates are increased, so that was an early signal, and it was serendipity that I happened to, because I didn't typically see patients all the time in our clinical center. I would see them in another location. I saw them and my colleagues saw them, like, the same day, and it was just by chance, so look out for those chance encounters. If there's something strange, you know, feel free to reach out to us and say, hey, are you seeing this? So just, that's one of the things that we find is you have to be alert to something weird. If it doesn't, if it gives you, you know, that spidey sense, don't ignore it and think about what it, that it could be an early signal. So with the beauty of this organization and this certification and training is the beauty of the case series and what the case series does. The original myeloma, one of those patients transferred from Mount Sinai to New Jersey, and he's luckily still alive, but that original article got so many people thinking about blood disgraces, and so that's really important, the whole concept of doing the case series. And the other thing to add to this is the autoimmune conundrum, which is how do you, are you a splitter or are you a lumper with respect to, so maybe it's IGA nephropathy or maybe it's autoimmune nephropathy, and how do you figure out that? And should that be included with rheumatoid arthritis in younger men and scleroderma in younger people that shouldn't really have that? So again, but you in Maryland, we're going to be doing this in an expanded form in the MarCom conference and Dr. Sandra Lowe's going to be here, is going to be with us, our mental health person, talk to us, but bring everything that we're doing in our world trade to the rest of your practice when you're doing it, because it really, the idea of knowing who your medical surveillance patients are, and finally for the last few people that are here, it helps to talk about sports with your patients, because that's my general pathway to get people into mental health care, is to talk about sports. It's not controversial, and if you can identify a team that the person likes, you can generally get them starting talking about the rest of their life. Thank you, everyone.

World Trade Center Health Program

9-11 attacks

toxic dust exposure

health screenings

respiratory issues

cancers

mental health disorders

autoimmune diseases

early detection

diverse populations

healthcare providers