Research to Care

Community Engagement Event on 9/11 Health
October 21, 2017

The World Trade Center (WTC) Health Program held the first ever Research to Care Community Engagement event on October 21st, 2017 to hear about new developments in 9/11 health research and learn how to maintain good health.

In the morning session, Dr. John Howard, the WTC Health Program Administrator, gave opening remarks, followed by two panels of leading researchers who each discussed the health effects from the 9/11 attacks and their recent research. For more information, see the Detailed Agenda.

Individual researcher presentation clips, transcripts, and fact sheets are available below.

Morning Session Transcript CME/CE Information

Individual Researcher Presentations

Afternoon Wellness Session

Panel 1

Lower Respiratory Symptoms in the WTC Survivor Program
Joan Reibman, MD, PhD
Director, NYU/Bellevue Asthma Center; Director of Health and Hospitals Corporation, WTC Environmental Health Center; Associate Professor of Medicine and Environmental Medicine

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Joan Reibman, MD: So good morning. It's a pleasure to be here. It's actually pretty amazing to stand here for, I don't know, almost 16 years, I guess, and see many of the faces that we have grown up with as we have been working to understand the health effects in the community that was near the World Trade Center. And so today I have a very short period of time and I'm tasked with telling you a lot of information, so I'm going to try to tell it as a bit of a story and put it in context because, again, this is a very diverse audience and I want it to be clear. So I'm the Medical Director of the World Trade Center Environmental Health Center for the survivors and community members, and my background, as you’ve heard, is really I began as an asthma doctor, asthma and environmental issues were my interest, and I've been at NYU and at Bellevue and at Health + Hospitals for many, many, many years, and I'm now a professor there.

What I would like to do is sort of start by giving you some definitions so that we're all talking the same vocabulary. And the definitions I want to give you are really, when we're talking about the respiratory system, we really think about it as one unit, but we break it up into upper and lower, the upper being your sinuses, nasal passages, and vocal cords, and the lower being your bronchi, the tubes in your lung that branch into many, many, many tubes and end up in small airways and in alveoli where you do gas exchange for oxygen and carbon dioxide. And it's important to understand that because that’s how we talk about respiratory disease or respiratory illness in the population that was exposed to World Trade Center dust and fumes, whether it's the responder population or a community population. And when we begin to understand what's happened to the airways, we start with really the first thing which is symptoms, and symptoms are how somebody feels. They're not a diagnosis. Upper airway symptoms are postnasal drip, fullness in the face, facial pain, cough. Lower airway symptoms are cough, shortness of breath, chest tightness, wheezing. And what you notice from this list is that there's overlap, that you can have symptoms that are upper airway that are also lower airway, and that a symptom really only tells you a problem, it doesn’t tell you a disease. It tells you that there's something going on that you have to figure out. So how do we figure that out? And that’s not so easy and that’s where the role of research comes in and that’s where understanding disease mechanisms come in. We do physical exams, we do questionnaires, and we also do tests, and we do a lot of tests, and we ask people who are coming into our programs to do a lot of tests. And those tests include many, but one of the first ones we always do is something called spirometry where we measure lung function, and when we're doing that, that gives us a lot of information, but there are a couple of—actually three main things it gives us. One is how much air you can blow out. That’s very important. The second is how fast can you blow that air out? Because you should be able to blow out almost all your vital capacity, that’s vital because it's vital for your life, how much air you can blow out, you should be able to blow most of that out in one second. And if you can't, it means that there's an obstruction in there and that that may be something that is blocking that airflow. And the good thing about spirometry for research is that it's used a lot, we have standard values, it's relatively easy to do, it's noninvasive. But the bad thing is that the normal values are epidemiologic, they may not pertain to you as an individual, often we do it at one time point so you don't know where you're starting from or going to, and also it tells you mostly large airway function. It doesn’t always tell you what's going on in those smaller airways. Also, it tells you a single point in time. So for example, in a disease like asthma which is variable, you may not catch the abnormalities at the time that you're doing spirometry. So spirometry, which is our standard that we start with, is enormously helpful, but it doesn’t tell us a whole story. So other tests you're going to hear about today that we can do are studies, for example, looking at twitchiness of the lungs, and we do that with what's called a methacholine challenge test. We take a chemical, we ask you to breathe it in, we measure your lung function, and that tells us how sensitive your airways are to external exposures, to other chemicals, for example, or just other exposures in the air.

So when we started our studies, we first had to understand what individuals—and I'm speaking here of community members, but clearly this pertains to others—had been exposed to, and how to describe the exposure, and how to link that exposure to symptoms and lung function. And although we never developed a perfect way to describe exposure in the community members, we've known now through studies we did with New York State Department of Health and then subsequently with the New York City Department of Health that we can think about exposures to community members as acute exposures, those that occurred on 9/11, as well as chronic exposures, those that occurred in response to the re-suspended dust and from the fumes from the fires that burned. And we now know that in fact, through these studies, that we can associate exposure with symptoms, so that gives us a dose response or an exposure response, and that's critical when we're talking about environmental health and understanding the impact of an environmental exposure. It's sort of the first thing you need to be able to do.

So then the question was: what was the disease? And early on we got clues from this from the fire department who described in fact airway hyper-responsiveness or twitchiness in the firefighters, and this made sense because, as we began to understand what was in that dust, we knew that it was caustic, that it had a pH of 11, and that that was going to in fact cause a burn, but there was something more to understand about that dust. And we knew that there were about 1.2 million tons of material that were deposited throughout Lower Manhattan and in Brooklyn, but for pulmonologists, you have to understand what is that dust made out of and also what's the size of that dust or the particles? Because size is important because it tells you where it's going to impact in the upper and the lower airways. And our dogma had always been that a particle that was larger than 5 micrometers was not going to get down into the deep airways and couldn’t therefore do damage, but might in fact do more damage to the upper airways. But we knew that, in fact, a lot of the particles weren't bigger than that, they were smaller, and so what we understood was that some of that was going to get past the normal protective mechanism, the mucociliary escalator which would protect your lungs, and might in fact get into the small airways.

But we weren’t sure how to look at that, but we wondered—we got clues that, in fact, some of these particles were getting deep into the lung. The first clue was from a firefighter who was admitted to Bellevue Hospital, got his lungs washed out, and we identified particles that were in fact large deep in his lungs, and this was published, this manuscript was published. We got additional clues from work done, again, in the firefighters by a woman aptly called Fireman, who many years later showed that sputum had particles, and we got clues from the survivor group when we did biopsies of some of these people and looked in the lungs themselves and saw particles within the lungs itself. But how could we look at this in a larger population and measure this? So when we began studying community members, we did spirometry, we looked at how much air you could blow out, how fast, and many people had symptoms, but had normal spirometry.

So we put in place another test that we didn’t fully understand called forced oscillation and this test was a noninvasive test and it was pretty easy to do. You just had to breathe regularly and hold your cheeks, and what this technique did was to measure how airflow is distributed in the lungs, and when there's disease, the airflow is no longer uniformly distributed, and so if there was disease in the small airways, we could detect abnormal measurements. So we did this routinely in our population and what we found was in fact there were lots of abnormalities, but we didn’t have normal, so we worked with the Department of Health, with the Registry, and we did a huge study, and we were able to show that in fact we could detect abnormalities associated with symptoms in people who had normal spirometry, suggesting that many of these people had small as well as large airway abnormalities.

I'm told I have to wrap up so I will move pretty quickly. But we now know that injury can be varied. We know that it depends not only on the size, on the components, but also on individual susceptibility. We also know that the damage can be heterogeneous, that it might present as asthma in one person and as a different disease in another person. And the question now, 16 years later, is what's happened to individuals who have these persistent symptoms? And the answer is varied. When we measured spirometry over time, we in fact saw improvement. In fact people seemed to be getting better in their large airway lung function. We haven't finalized our analysis of the small airways. We looked at causes and we looked at components of inflammation and we showed that in fact there's a variety of types of inflammation that we can see in our population, not surprising if you understand the asthma literature, but we showed that in fact some people had eosinophils as a type of inflammation that was associated with some of their symptoms, other people had elevation in different types of systemic inflammation that was associated with small airway disease.

And then most recently with funding from the Centers for Disease Control, we've asked a number of people to come in, we have put them on a high-dose medication for asthma, we have asked did their symptoms improve or stay improved? And in fact what we found, almost 80 people participated in this pretty intensive study, and what we have found is that in fact, despite being on all these medications, some of them still had symptoms, lower respiratory symptoms. So we put these people through a battery of tests, very detailed, we did extensive lung function testing, we looked for airway hyper-responsiveness, we did a vocal cord evaluation. And the data is still not published and not fully analyzed and we're still looking at it, but what it's beginning to suggest is that many of these people still have persistent twitchiness, twitchiness in their airways, twitchiness in their vocal cords, and also some abnormalities in their small airways. And this is very important for us because, as we talk about going in the future, this helps us figure out how do we need to now manage these individuals? What are the medical approaches that we can do? How do we target the treatments that we're going to need to do? And also tells us that there's more to learn and we need to think about how else to approach many of you who still have symptoms, although, as our data is also showing, many people are beginning to improve and have resolved their symptoms as well. So I hope I did that in a short time. Thank you very much.

Study Fact Sheet
Lower Respiratory Symptoms (LRS) in the WTC Survivor Program

Potential Impact: The study focused on identifying areas in the lungs which may cause respiratory symptoms. Understanding how to identify these areas will help with early detection of disease, diagnoses and future treatment. The study may help reduce lower respiratory symptoms and improve lung function of the WTC population. It may also reduce other health problems that occur with lower respiratory symptoms.

Research: Many World Trade Center Health Program members have lower respiratory symptoms despite treatment. We have previously used studies to measure abnormalities in the small airway that participate in these symptoms. We are now also studying patients who received strong medical therapy for persistent lower respiratory symptoms to understand why their symptoms persist. We examine lung function using multiple techniques, vocal cord and airway hyperresponsivness, and markers of inflammation and presence of additional illnesses.

Population: Patients in the WTC Environmental Health Center who have had tests to measure how well their lungs worked at their initial exam and later monitoring visits. These lung tests are called spirometry and impulse oscillometry (IOS) tests.

Findings: Most people in the study with Post-9/11 LRS have had some improvement in symptoms. Many have had improvement in spirometry. However, one-third of the people in the study have continued to have respiratory symptoms even though their spirometry tests were normal during their follow up exams. Many of the patients with normal spirometry tests had abnormal IOS test results suggesting that the small airways of the lung may be affected. Many patients also continue to show airway hyperresponsivness (twitchy lungs), or hyperresponsivness of their vocal cords. We also found that PTSD was associated with lower respiratory symptoms. These findings are associated with some markers of inflammation. Our findings suggest that here may be multiple causes of persistent respiratory symptoms, some of which occur together. Treatment needs to be targeted to these multiple causes.

Síntomas en las vías respiratorias inferiores (LRS) de los pacientes del Programa de Sobrevivientes del WTC

Impacto potencial: El estudio se concentró en identificar las áreas de los pulmones que podrían causar síntomas respiratorios. Comprender cómo identificar estas áreas ayudará a detectar temprano las enfermedades, el diagnóstico y el tratamiento futuro. El estudio quizás ayude a reducir los síntomas en las vías respiratorias inferiores y mejorar la función pulmonar de la población del WTC. También podría reducir otros problemas de salud que ocurren con estos síntomas.

Investigación: Muchos miembros del Programa de Atención Médica del WTC tienen síntomas en las vías respiratorias inferiores a pesar del tratamiento. En el pasado, usamos estudios para medir las anormalidades en la pequeña vía respiratoria que participa en estos síntomas. Ahora estamos estudiando a los pacientes a los que se les proporcionó una fuerte terapia médica para los síntomas persistentes en las vías respiratorias inferiores con el fin de comprender por qué esos síntomas continúan. Examinamos la función pulmonar por medio de varias técnicas, la hiperrespuesta de las cuerdas vocales y de las vías respiratorias, marcadores de inflamación y la presencia de enfermedades adicionales.

Población: Pacientes del Centro de Salud Ambiental del WTC a los que les habían realizado pruebas para medir el funcionamiento de los pulmones en su visita inicial y en visitas de supervisión posteriores. Estas pruebas de la función pulmonar se llaman espirometría y oscilometría de impulso (IOS, por sus siglas en inglés).

Hallazgos: La mayoría de las personas en el estudio con síntomas en las vías respiratorias inferiores posteriores al 9/11 han tenido alguna mejoría en sus síntomas. Muchas han mostrado una mejoría en la espirometría. Sin embargo, un tercio siguió teniendo síntomas respiratorios aun cuando el resultado de la espirometría fue normal durante sus visitas de seguimiento. Muchos de los pacientes con resultados normales en las espirometrías tuvieron resultados anormales en la IOS, lo cual sugiere que las pequeñas vías respiratorias de los pulmones podrían estar afectadas. Muchos pacientes también continuaron mostrando hiperrespuesta de las vías respiratorias (pulmones espasmódicos) o hiperrespuesta de sus cuerdas vocales. También hallamos que el TEPT estaba asociado a los síntomas de las vías respiratorias inferiores. Estos hallazgos están relacionados con algunos marcadores de inflamación. Nuestros hallazgos sugieren que aquí podría haber varias causas para los síntomas respiratorios persistentes, algunas de las cuales ocurren juntas. El tratamiento debe dirigirse a estas causas múltiples.

Objawy w dolnych drogach oddechowych w Programie WTC dla Osób Ocalałych

Potencjalny wpływ: Badanie koncentruje się na identyfikacji obszarów w płucach, które mogą powodować objawy ze strony układu oddechowego. Zrozumienie, jak zidentyfikować te obszary, pomoże we wczesnym wykrywaniu chorób, diagnostyce i leczeniu w przyszłości. Badanie może pomóc w łagodzeniu objawów ze strony dolnych dróg oddechowych i w poprawie czynności płuc w populacji WTC. Może też łagodzić inne problemy zdrowotne, które występują obok objawów w dolnych drogach oddechowych.

Badanie: Wielu członków Programu Ochrony Zdrowia World Trade Center odczuwa objawy w dolnych drogach oddechowych, pomimo leczenia. Wcześniej wykorzystywaliśmy badania do pomiaru nieprawidłowości w mniejszych drogach oddechowych, które również należą do tych objawów. Obecnie badamy także pacjentów, którzy przeszli silną terapię lekową w związku z uporczywymi objawami w dolnych drogach oddechowych, aby zrozumieć, dlaczego objawy nie ustępują. Badamy czynność płuc z zastosowaniem wielu technik, nadwrażliwość strun głosowych i dróg oddechowych oraz markery stanu zapalnego i występowania dodatkowych chorób.

Populacja: Pacjenci Środowiskowego Centrum Zdrowia WTC, którzy przeszli badania mierzące czynność płuc na wizycie początkowej oraz później, podczas wizyt kontrolnych. Te badania to spirometria i oscylometria impulsowa (IOS).

Ustalenia: Większość uczestników badania z objawami w dolnych drogach oddechowych będących skutkiem 9/11, odczuła pewne złagodzenie objawów. U wielu wystąpiła poprawa w spirometrii. Jednak jedna trzecia osób biorących udział w badaniu w dalszym ciągu wykazuje objawy ze strony układu oddechowego, pomimo że wyniki spirometrii podczas wizyt kontrolnych były prawidłowe. Wielu pacjentów z prawidłowymi wynikami spirometrii miało nieprawidłowe wyniki testu IOS sugerujące, że małe drogi oddechowe mogą być zajęte. Wielu pacjentów nadal wykazuje objawy nadwrażliwości dróg oddechowych (niespokojne płuca) lub nadwrażliwości strun głosowych. Zauważyliśmy również, że zespół PTSD był powiązany z objawami w dolnych drogach oddechowych. Te wyniki są powiązane z niektórymi markerami stanu zapalnego. Wyniki sugerują, że może istnieć wiele przyczyn występowania uporczywych objawów w drogach oddechowych, w tym niektóre występują wspólnie. Leczenie musi być nakierowane na wszystkie przyczyny.

WTC 倖存者計劃中的下呼吸道症狀 (LRS)

潛在影響: 本研究重點是確定可能導致呼吸系統症狀的肺部區域。瞭解如何識別這些區域將有助於及早發現疾病、診斷和未來治療。這項研究可能有助於減少下呼吸道症狀,改善 WTC 人群的肺功能。它也可以減少其他與下呼吸道症狀相關的健康問題。

研究: 雖然許多世界貿易中心健康計劃會員已接受治療,但仍患有較輕的呼吸道症狀。我們以前曾使用研究來檢測涉及這些症狀的小氣道的異常情況。我們現在還在研究接受強效藥物治療的下呼吸道症狀持續的患者,以瞭解為什麼他們的症狀持續存在。我們使用多種技術檢查肺功能、聲帶、氣道高反應性、發炎標記物,以及是否患有其他疾病。

人群: WTC 環境健康中心的患者進行了測試,以檢測其肺部在初次檢查和後來的監測訪視中的工作情況。 這些肺部測試稱為肺活量測試和脈衝振盪 (IOS) 測試。

研究結果: 大多數接受 9/11 LRS 後的研究對象的症狀有所改善。許多人的肺活量測定有所改善。然而,三分之一的研究對象在後續追蹤檢驗期間仍然存在呼吸系統症狀,儘管其肺功能測試正常。許多肺活量檢驗正常的患者的 IOS 測試結果異常,提示肺部小氣道可能受到影響。許多患者還繼續表現出氣道高反應性(肺部抽搐)或聲帶的高反應性。我們還發現 PTSD 與下呼吸道症狀有關。這些發現與一些發炎標記物有關。 我們的研究結果表明,這可能是多種持續性呼吸系統症狀的原因,而一些症狀會同時發作。治療需要針對這些多種原因。


Pulmonary Health Effects in WTC Responders
Laura Crowley, MD
Deputy Medical Director, Selikoff Centers for Occupational Health, Mt. Sinai Hospital; Associate Professor, Environmental Medicine & Public Health

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Laura Crowley, MD: Thank you, Dr. Moline. Good morning. First of all, I'd like to thank you all, especially NIOSH, for the opportunity and invitation to speak today. I am under the direction of Dr. Crane, who is sitting to my right and Dr. Lucchini who is up on the panel now, and I'm with the Mount Sinai Responder Program. I'm going to do my best to follow Dr. Reibman and speak briefly about where we are with regards to lower airways disease. I do not intend to go over every publication that’s been published to date regarding lower airway disease, because that would be an entire day, but really just touch upon how we got to where we are today and the pattern that kind of brought us here. So there's certainly been a number of studies through the World Trade Center Program evaluating lung conditions in those exposed, and all of these have contributed in some way, shape, or form to what we know about lung disease in our responders and survivors today. The keyword is "all", and I'd like to pivot off of what Dr. Howard said in terms of needing more than one study to show evidence that there's disease in this population, and we've been fortunate enough to work very closely with our colleagues, both at the Survivor Program and with FDNY, to work together in research and show that certain diseases are cropping up in all of our cohorts.

So currently the World Trade Center Program covers several lung conditions – asthma, COPD, sarcoidosis, interstitial lung disease – and we'll certainly be talking more about these later today. However, the history behind how these conditions came to be covered conditions really should not be ignored. It certainly gives us perspective as to what has been done to date and it really sets the stage for considering how we're going to move forward. So in taking a step back and reflecting on what Dr. Reibman said earlier, early on with exposure, we were seeing immediate symptoms, both upper and lower airway, specific to lower airway, as Dr. Reibman mentioned, cough, shortness of breath, wheezing, tightness in the chest, and certainly it was at this point when physicians were seeing these symptoms, it was like a red flag. So thinking about the research around that time, it was very symptom-driven, and in 2004, there was a group of physicians that banded together looking at about 96 ironworkers that worked at the site between September 11 and February of 2002. And it really had a pretty big impact because it showed that 77% of the patients were complaining of respiratory symptoms, with cough being the most common. In addition, there was the five-year study that was put out and published by Dr. Moline, Dr. Herbert, and Dr. Levin that similarly found elevated respiratory symptoms and abnormal breathing studies.

Most of you are familiar with those tests that we do on a year to year basis to evaluate lung function, as Dr. Reibman described. So those objective tests became very important because they justified that what we were seeing from a symptom perspective could be acknowledged in a data way. So in the study that Dr. Moline published with Dr. Herbert, we picked up that forced vital capacity, which is a number that we look at on the breathing test, was noted to be abnormal in 24% of our patients. Forced vital capacity is basically representative of, when a patient takes a deep breath in, it assesses how well they're able to blow all that air out, and 24% of our patients were showing an abnormal value. So why was this important? Well, one, we had that objective data point along with symptoms. And two, it realized, you know what? These symptoms shouldn’t be ignored and we really need to monitor these folks for long-term surveillance purposes to see if these numbers continue to decline, stabilize, or if there are any other conditions that may be associated with these abnormal parameters.

So in addition to the breathing test, we started to look obviously at chest x-ray, CAT scan, and evaluate the impact of what we were seeing in our patients with regards to those imaging studies. And in 2007, Dr. de la Hoz and his colleagues looked at CAT scans in our responders and found that we were seeing some abnormalities in the airways that are much deeper in the lungs. So it was at that point in time when we realized, well, certainly diseases more in the upper area, like asthma, bronchitis, and cough, were of concern because that was immediate and acute exposure, but then long-term effects, was that going to have an effect deeper down in the lungs, in the lung tissue? And we realized shortly after, with the research that the fire department put out, that there was a disease called sarcoidosis which shows that the lungs can get inflamed and have enlarged lymph nodes, was cropping up in the cohort. And it was around 2006 when we had a federally-funded program for a treatment program and it was at that point in time when we were categorizing diseases and figuring out which diseases could be covered. And we had asthma, bronchitis, chronic cough, and COPD, but with the literature that Mount Sinai put out and the literature that the fire department put out actually before us, we were able to say, you know what? Sarcoidosis is probably one of those conditions we should put on the list. Shortly after, there was a publication by Dr. Moline and some pathologists, it was identifying that interstitial lung disease, which is a scarring of the lungs that can happen, was noted to be found in seven of prior healthy patients. That was concerning, we flagged it, and it was considered a covered condition.

So this just goes to show you that, as time has progressed, the thought process behind research has evolved. So it starts out with symptoms, and then objective testing, and then we categorize the disease, and then moving forward, we've come to understand that comorbid World Trade Center disease plays a role as well. And it was in 2011 when Dr. Wisnivesky looked at our 27,000 responders and identified that we were seeing elevated cumulative incidence of asthma, sinusitis, GERD, kind of looking at the population as a whole in terms of all the different types of diseases that we were seeing and how it was impacting respiratory upper/lower, GI, and mental health.

So this kind of brings us to where we are now with research. So we have symptoms, objective findings, disease recognition, and now led to evolution of care in terms of inclusion of lower airway disease, and interaction of these conditions and comorbidities, and understanding the progression, and how some of these diseases may stabilize or progress, and how can best manage and treat. Currently, Dr. Wisnivesky is working at Mount Sinai on looking and assessing inflammatory and behavioral pathways linked to PTSD and increased asthma morbidity. Prior to that, he assessed how we can best monitor patients with asthma in our World Trade Center population and determine the best course of treatment and management interventions. Dr. de la Hoz, who is here today, will be speaking about his study regarding pulmonary disease and CAT scan and how it correlates to respiratory symptoms in our responders, breathing tests, and their occupational exposure.

So to attempt to sum up the importance of the program in a few lines would not really do it justice, but what we can say, it's important to note that the World Trade Center Program works to provide excellence in care for all our patients, to learn from our responders, survivors, and volunteers by studying World Trade Center covered conditions and how we can better monitor and treat these conditions, and certainly to use the lessons learned to maybe even understand areas of disease that remain a bit of a mystery and are less understood in clinical medicine to date. So with that, we and I extend a special thank you to all of the responders, survivors, and all of our partners at labor, and certainly of course Dr. Howard and NIOSH. Thank you very much and looking forward to an exciting day.

Study Fact Sheet
Pulmonary Health Effects in World Trade Center (WTC) Responders

There have been a number of studies by the WTC Health Program Clinical Centers of Excellence evaluating lung conditions in patients exposed to the WTC dust and debris. These studies have all contributed in some way to what we know about lung disease in our responders and survivors today. The WTC Health Program currently covers lung conditions like: asthma, chronic obstructive lung disease, sarcoidosis, and interstitial lung disease. The research evaluating lower airway disease in WTC responders continues to contribute significantly to understanding persistent symptoms in our patients. In addition, it highlights the need for continued research to properly monitor, treat and care for WTC responders with lung disease.

Prognosis and Determinants of Asthma Morbidity in WTC Rescue and Recovery Workers

Dr. Juan Wisnivesky’s study evaluates exposure history, treatment needs, evaluation of the influence of comorbidities on disease presentation, and the impact of World Trade Center related asthma on the quality of life of WTC workers. This study provided additional information to WTC workers diagnosed with asthma so they may monitor their disease course, select the best course of treatment and provide potential self-management interventions for workers with asthma.

Assessing Inflammatory and Behavioral Pathways Linking PTSD to Increased Asthma Morbidity in WTC Workers

Asthma and Post-Traumatic Stress Disorder (PTSD) are also the most common conditions in WTC rescue and recovery workers. Dr. Juan Wisnivesky’s study will evaluate specific laboratory values and relationship between PTSD and increased asthma morbidity. The study will also pilot test a an intervention to improve outcomes of WTC workers with asthma and PTSD.

Pulmonary Diseases in WTC Workers: Symptoms, Function, and Chest CT Correlates

Dr. Rafael E de la Hoz evaluated all chest CT scans performed on WTC workers and volunteers at the Mount Sinai Medical Center between 2003 and 2016. The CT scan were then reviewed in detail by radiologists, and by special computer programs, to detect and measure abnormalities related to all types of lung disease. The CT scan abnormalities were then compared with responder respiratory symptoms, breathing test results, and occupational exposures. This study also evaluated trends in lung function over time, and seeks to characterize the WTC related lung diseases and their risk factors, with a special focus on obesity-related indicators.

Efectos en la salud pulmonar de los miembros del personal de respuesta del World Trade Center (WTC)

Los Centros de Excelencia Clínica del Programa de Atención Médica del WTC han realizado una cantidad de estudios para evaluar las afecciones pulmonares en los pacientes que estuvieron expuestos al polvo y a los escombros del WTC. Todos estos estudios han contribuido de alguna forma a lo que hoy sabemos sobre la enfermedad pulmonar en el personal de respuesta y los sobrevivientes. El Programa de Atención Médica del WTC actualmente cubre afecciones pulmonares como asma, enfermedad pulmonar obstructiva crónica, sarcoidosis y enfermedad pulmonar intersticial. La investigación que está evaluando las enfermedades de las vías respiratorias inferiores en el personal de respuesta del WTC sigue ayudando significativamente a comprender los síntomas persistentes en nuestros pacientes. Además, resalta la necesidad de continuar investigando para monitorear, tratar y atender adecuadamente al personal de respuesta del WTC afectado por enfermedades pulmonares.

Prognosis y determinantes de la morbilidad del asma en los trabajadores de rescate y recuperación del WTC

Un estudio realizado por el Dr. Juan Wisnivesky evalúa los antecedentes de exposiciones, las necesidades de tratamiento, la influencia de las comorbilidades en la presentación de la enfermedad, y el impacto del asma relacionado con el World Trade Center en la calidad de vida de los trabajadores del WTC. Este estudio suministró información adicional para los trabajadores del WTC con diagnóstico de asma para que se pueda seguir el desarrollo de su enfermedad, elegir el mejor curso de tratamiento y adoptar posibles intervenciones para el autocontrol de esta afección.

Evaluación de las secuencias inflamatorias y de comportamiento que vinculan el trastorno de estrés postraumático a un aumento en la morbilidad del asma en los trabajadores del WTC

El asma y el trastorno de estrés postraumático (TEPT) son también las afecciones más comunes en los trabajadores de rescate y recuperación del WTC. El estudio del Dr. Juan Wisnivesky evaluará valores analíticos (de laboratorio) específicos y la relación entre el TEPT y el aumento en la morbilidad del asma. El estudio hará también una prueba piloto de una intervención para mejorar los resultados en los trabajadores del WTC con asma y TEPT.

Enfermedades pulmonares en los trabajadores del WTC: Correlatos de síntomas, función y tomografía computarizada de tórax

El Dr. Rafael E. de la Hoz evaluó todas las tomografías computarizadas de tórax que se les hicieron a trabajadores y voluntarios del WTC en el Centro Médico Mount Sinai entre el 2003 y el 2016. Las tomografías computarizadas fueron luego analizadas en detalle por radiólogos y por programas de computación especiales para detectar y medir las anormalidades relacionadas con todos los tipos de enfermedad pulmonar. Las anormalidades se compararon después con los síntomas respiratorios, los resultados de las pruebas de función respiratoria y las exposiciones ocupacionales. Este estudio también evaluó las tendencias en la función pulmonar a lo largo del tiempo. Su objetivo es caracterizar las enfermedades pulmonares relacionadas con el WTC y sus factores de riesgo, con un enfoque especial en los indicadores relacionados con la obesidad.

Choroby płuc u Ratowników World Trade Center (WTC)

W Klinicznych Centrach Doskonałości Programu WTC przeprowadzono wiele badań, które oceniały stan zdrowia płuc u pacjentów narażonych na działanie pyłu i gruzu z WTC. Badania przyczyniły się do poszerzenia naszej wiedzy na temat chorób płuc występujących obecnie u ratowników i osób ocalałych. Program WTC obejmuje obecnie następujące choroby płuc: astma, przewlekła obturacyjna choroba płuc, sarkoidoza oraz śródmiąższowa choroba płuc. Badania dotyczące chorób dolnych dróg oddechowych u ratowników WTC znacząco przyczyniają się do zrozumienia uporczywych objawów występujących u naszych pacjentów. Ponadto zwracają uwagę na potrzebę ich kontynuowania, dla celów właściwego monitorowania, leczenia i opieki nad ratownikami WTC cierpiącymi na choroby płuc.

Rokowania i uwarunkowania zachorowalności na astmę u osób pracujących przy akcji ratowniczej WTC

Badanie dra Juana Wisnivesky'ego ocenia historię ekspozycji, wymagania dotyczące leczenia, wpływ współistniejących chorób oraz wpływ astmy powiązanej z World Trade Center na jakość życia pracowników WTC. Badanie to dostarczyło dodatkowych informacji pracownikom WTC z rozpoznaną astmą, dzięki czemu mogą oni śledzić przebieg swojej choroby, wybrać najlepszą metodę leczenia i stosować potencjalne samodzielne stosowanie interwencji.

Ocena stanów zapalnych i zaburzeń behawioralnych łączących PTSD ze zwiększoną zachorowalnością na astmę u pracowników WTC

Astma i zespół stresu pourazowego (PTSD) to również najczęstsze choroby występujące u osób pracujących przy akcji ratunkowej WTC. Badanie dra Juana Wisnivesky'ego oceni konkretne wartości laboratoryjne oraz związki między PTSD i zwiększoną zachorowalnością na astmę. Badanie będzie również obejmowało pilotową próbę interwencji mającej na celu poprawę wyników u pracowników WTC z astmą i PTSD.

Choroby płuc u pracowników WTC: Objawy, funkcje i korelacje z TK klatki piersiowej

Dr Rafael E. de la Hoz ocenił wszystkie badania TK klatki piersiowej wykonane u pracowników i wolontariuszy WTC w Mount Sinai Medical Center w latach 2003-2016. Wyniki badań TK zostały następnie szczegółowo przeanalizowane przez radiologów oraz specjalne programy do wykrywania i mierzenia nieprawidłowości związanych z wszelkiego rodzaju chorobami płuc. Nieprawidłowości w wynikach badań TK porównano następnie z objawami ze strony układu oddechowego, występującymi u ratowników, wynikami testów wydolności oddechowej i narażeniem zawodowym. Badanie to ocenia również tendencje w funkcjonowaniu płuc na przestrzeni czasu i próbuje scharakteryzować choroby płuc związane z WTC oraz ich czynniki ryzyka, ze szczególnym uwzględnieniem wskaźników związanych z otyłością.

世界貿易中心 (WTC) 救助人員 的肺健康影響

WTC 健康項目臨床卓越中心已有許多研究針對接觸 WTC 灰塵和碎屑之患者肺部狀況進行評估。這些研究在某些方面,對我們目前所瞭解之救助人員和倖存者中肺病都有所貢獻。WTC 健康計劃目前涵蓋肺部疾病,如:哮喘、慢性阻塞性肺病、肉狀瘤病和間質性肺病。在 WTC 救助人員中評估下呼吸道疾病的研究可極大幫助瞭解患者中的持續症狀。此外,還強調需要繼續研究,以妥善監測、治療和護理患有肺病的 WTC 救助人員。

WTC 救援和復原工作者中哮喘發病的預後和決定因素

Juan Wisnivesky 醫生的研究評估暴露史、治療需求、合併症對疾病病情的影響評估,以及世界貿易中心相關哮喘對 WTC 工作者生活品質的影響。該研究為診斷為哮喘的 WTC 工作者提供額外資訊,以便他們可以監測其病程、選擇最佳治療方案,並為哮喘工作者提供潛在的自我管理干預措施。

評估發炎和行為途徑將創傷後壓力 症 (PTSD) 與 WTC 工作者中哮喘發病率升高關聯起來

在 WTC 救援和復原工作者中,哮喘和創傷後壓力症 (PTSD) 也是最常見的情況。Juan Wisnivesky 醫生的研究將評估 PTSD 與哮喘發病率增加之間的特定檢驗值和關聯。該研究還將進行一項干預先導試驗,以改善患有哮喘和 PTSD 之 WTC 工作者的結果。

WTC 工作者中的肺病:症狀、功能和胸部 CT 相關問題

Rafael E de la Hoz 醫生評估 WTC 工作人員和志願者在 2003 年至 2016 年在西奈山醫療中心進行的所有胸部 CT 掃描。然後由放射科醫師和特殊電腦程式詳細審查 CT 掃描,以檢測和測量與所有肺病類型有關的異常情況。 之後將 CT 掃描異常與救助人員的呼吸症狀、呼吸測試結果和職業暴露進行比較。本研究還評估隨時間而發展之肺功能的趨勢,並試圖描述 WTC 相關的肺病及其危險因素,特別關注與肥胖有關的指標。


Post-9/11 Cancer Among the World Trade Center General Responders Consortium
Roberto Lucchini, MD
Professor, Environmental Medicine and Public Health, Professor, Medicine, Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai

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Roberto Lucchini, MD: Thank you, Jackie. Thank you. I would like to thank everybody for inviting me. This is a great opportunity. Thank you, Max, for putting it together, Tania and Dr. Howard and all these excellent, great colleagues. It's a pleasure for me to be here. So when we talk about cancer, of course we have to focus on carcinogens, so this is why we're here and this is why we're talking about cancer. So talking about the carcinogens is the most important point here that we have to focus on, all right? So we have a list of them and this is information that we have because of measurement that had been done on the settled dust. The settled dust is the dust that deposits after whatever happens, so you can collect this dust and you can do a lot of analysis, and that analysis is extremely, extremely important for our knowledge. This is the first, always, exposure assessment, it's called, exposure sciences, this is a very important field for us in occupational and environmental health because we are dealing with exposure constantly, so we need to know very well, as much as we can, what are we dealing with?

So in terms of exposure, in terms of the analysis in the deposited dust, we have chrysotile asbestos, everybody knows about asbestos, and so I don't need to talk about this further, because it's a very powerful carcinogen. Unfortunately it was present in the buildings. When the building collapsed, a huge amount of asbestos came out and that became the exposure. Then we had—well, lead is another carcinogen according to IARC nowadays, then PCBs, polychlorinated biphenyls, and benzene, benzene is another important carcinogen we have known for many years in occupational health. And the list goes on with dioxin and diesel. So this is a mix of carcinogens that is unprecedented, so I think this is an important knowledge for us to maintain.

Of course we are exposed to carcinogens, unfortunately, every day. We breathe carcinogens, we are exposed to them, but that was a particular story. That was a special moment where the people, the responders, the workers, and the survivors, and the community were exposed to a high mix of carcinogens, and not only that, our knowledge about these carcinogens is based on the exposure to each one of them, right? So here we have a mixture, a co-exposure to different carcinogens, so the knowledge that exists about this co-exposure to a mix of carcinogens is not exactly the knowledge that we have based on each one of them. This is an important point to maintain.

Before coming to this program in 2012, you can tell by my accent, I have been working for 20 years in Northern Italy in the area of Milan. In that area, in the Seventies, there was an outbreak of dioxin because of the first episode of a toxic cloud; it was an industrial accident. And in that case, it was the exposure to dioxin, just one chemical that happened to be a carcinogen too, and research in that case was very, very important. Even now, many years later, research is still going on, and it's very important also as an example of this kind of relationship with the community where it's important to maintain feedback between the researchers and the members of the programs. So it's important, this knowledge about the exposure, and it's important for us to study about the health effects. It's not easy. It's an important challenge. We have to collect data and we need to match data with registries, registries for many states, because we have to collect the numbers of all these cases of these cancers, so this is a very, very important challenge and it's a very important activity that is ongoing, basically.

What we know, and actually I would say that, as Dr. Moline just said, the importance of this is there is a latency period before these cancers are actually identifiable. So before waiting for the latency period, it was very, very important for the program to recognize that cancer can be certified and treated by the program. So this is very, very important. It's important to continue with the research because we need to know the details, we need to know whether there are other emerging problems, but it's important that the program actually has this opportunity to treat cancers that are affecting the responders and the community. The first studies, I think three important studies came out in 2012, 2013. These are the first studies that came out from the firefighters, the Registry, and the General Consortium. These three studies were actually done in more or less the same time, but the data were updated to 2008, so now we need to update all this information, but already there, in 2008, it was already clear that there was an excess of all types of cancer, and especially of thyroid, prostate, but also some other cancers like melanoma not restricted to the skin and non-Hodgkin's lymphoma and multiple myeloma.

So this was the first evidence that came out in those years, and now we are continuing to update these results, and it's going to be important to understand what's going to happen in the future. There is an important new study which has actually been funded and this study will be actually one merged cohort and this is going to be a cohort of FDNY, the General Responder Cohort, and the Registry. This is going to be a very powerful new study because the three cohorts will be merged into one, so this is going to be a better statistical power, kind of more uniform access to the cases, and a better scientific approach, in a way, than before because it's going to be everything in one only study. And we are just starting now to collect data and to work on all the procedures, IRBs, and all the complicated, I would say, process that will make this happen. So I will stop here, so hopefully this is enough for now. And an important point I will say one more time, it's important that this program has cancer as a certifiable condition already, and it's also important that research is continuing to clarify and to give us more information and updates on what's going on in the long term. Thank you for your attention.

Study Fact Sheet
Post-9/11 Cancer among the World Trade Center General Responders

Potential Impact: The fndings from this study may help us know which screening tests can fnd early stages of cancers in World Trade Center (WTC) Health Program Responders.

Research: The study looked at whether a high dose exposure to the cancer causing toxins on or after 9/11 causes more cancers among Responders in WTC Health Program. Data on cancer from WTC Responders will be linked cancer registries in New York and other state cancer registries. (Cancer registries collect data about how many people in each state have cancer). Researchers will look at how often cancer occurred among the WTC Responders compared to the general population.

Population: This study looked at Responders, clean-up workers, and other workers who were in lower Manhattan in the weeks and months after 9/11. It used data from three WTC groups: FDNY, the Health Registry, and the WTC General Responders Consortium.

Findings: After 16 years from the exposure to carcinogens, an increase of cancers is observed in the three different WTC groups. For example, prostate cancer in WTC-patients is of a more aggressive type and appears at a younger age (<49 years on average) than in the non-WTC patients. A new study will create one unique WTC group where the cancer data will be studied in the same way.

Casos de cáncer posteriores al 9/11 en miembros del personal de respuesta general del World Trade Center

Impacto potencial: Los hallazgos de este estudio podrían ayudarnos determinar cuáles pruebas de detección pueden descubrir las etapas tempranas de los cánceres en miembros del personal de respuesta que forman parte del Programa de Atención Médica del WTC.

Investigación: El estudio analizó si una alta dosis de exposición a toxinas que causan cáncer, ocurrida el 9/11 o después, provoca más casos de esta enfermedad en los miembros del personal de respuesta que forman parte del Programa de Atención Médica del WTC. Los datos relacionados con el cáncer de miembros del personal de respuesta del WTC serán asociados a registros de cáncer de Nueva York y de otros estados. (Los registros de cáncer recogen datos sobre la cantidad de personas que tienen esta enfermedad en cada estado). Los investigadores observarán con qué frecuencia se han dado casos de cáncer en los miembros del personal de respuesta del WTC, en comparación con la población en general.

Población: Este estudio observó a los miembros del personal de respuesta, a trabajadores de limpieza y remoción de escombros y a otros trabajadores que estuvieron en el Bajo Manhattan en las semanas y meses posteriores al 9/11. Utilizó datos provenientes de tres grupos del WTC: FDNY, el Registro de Salud y el Consorcio de Personal de Respuesta General del WTC.

Hallazgos: Después de 16 años desde la exposición a carcinógenos, se ha observado un aumento en los casos de cáncer en tres grupos diferentes del WTC. Por ejemplo, el cáncer de próstata en los pacientes relacionados con el WTC es de un tipo más agresivo y aparece a edades más tempranas (<49 años en promedio) que en los pacientes que no están relacionados con el WTC. Un nuevo estudio creará un grupo del WTC exclusivo, donde los datos del cáncer se estudiarán de la misma manera.

Zachorowania na raka po 9/11 wśród Ratowników niewyspecjalizowanych World Trade Center

Potencjalny wpływ:: Ustalenia dokonane na podstawie tego badania mogą pomóc nam zrozumieć, które badania przesiewowe można zastosować we wczesnych stadiach raka u Ratowników należących do Programu Ochrony Zdrowia World Trade Center (WTC).

Badanie: W badaniu oceniano, czy duża dawka ekspozycji na rakotwórcze toksyny podczas lub po ataku 9/11 zwiększa częstotliwość występowania nowotworów u Ratowników należących Programu Ochrony Zdrowia WTC. Dane na temat nowotworów występujących u Ratowników WTC zostaną powiązane z rejestrami nowotworów – nowojorskimi oraz stanowymi. (Rejestry nowotworów zawierają dane o tym, ile osób w każdym stanie choruje na raka). Naukowcy przyjrzą się kwestii częstości występowania raka wśród Ratowników WTC, w porównaniu do populacji ogólnej.

Populacja: Badaniem objęto Ratowników, osoby pracujące przy oczyszczaniu oraz innych pracowników, którzy przebywali na Dolnym Manhattanie w tygodniach i miesiącach po 9/11. Wykorzystano dane z trzech grup WTC: FDNY, Rejestr Medyczny oraz Konsorcjum Ratowników Niewyspecjalizowanych WTC.

Ustalenia: Po 16 latach od ekspozycji na czynniki rakotwórcze, zaobserwowano zwiększoną liczbę występowania nowotworów w trzech różnych grupach WTC. Na przykład, rak prostaty u pacjentów WTC jest bardziej agresywny i występuje w młodszym wieku (średnio <49 lat) niż u pacjentów nie związanych z WTC. Nowe badanie umożliwi utworzenie jednej unikatowej grupy WTC, dla której dane dotyczące nowotworów zostaną przeanalizowane w taki sam sposób.

世界貿易中心一般救助人員 中的 9/11 後癌症

潛在影響: 本研究的研究結果可能有助於我們瞭解哪些 篩檢試驗可以發現世界貿易中心 (WTC) 健康計劃救助人員的癌症早期階段。

研究: 該研究考察了在 9/11 事件時或之後高劑量暴露於引起毒素的癌症是否在 WTC 健康計劃的救助人員中導致更多的癌症。WTC 救助人員的癌症數據將與紐約癌症登記系統和其他州癌症登記系統關聯起來。(癌症登記系統收集關於每個州有多少人患癌症的數據)。研究人員將研究與普通人群相比,WTC 救助人員發生癌症的頻率。

人群: 本研究在 9/11 之後的幾個星期和幾個月裡,考察了曾進入曼哈頓下城的救助人員、清理工人和其他工人。研究使用了三個 WTC 組的數據:FDNY、健康狀況登記系統和 WTC 一般救助人員聯合會。

研究結果: 在接觸致癌物質 16 年後,在三個不同的 WTC 組中觀察到癌症發病率增加。例如,WTC 患者的前列腺癌是一種更具侵襲性的類型,與非 WTC 患者相比,呈現低齡化(平均<49 歲)。一項新的研究將創建一個獨特的 WTC 小組,癌症數據將以相同的方式進行研究。


Post-9/11 Cancer Incidence in FDNY Firefighters
Mayris Webber, DrPH
Professor, Department of Epidemiology & Population Health, Albert Einstein College of Medicine

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Dr. Webber: Thank you so much. Thank you. That was very kind. So we are lucky at FDNY because we had an occupational health service that was well in place for years before 9/11, so it does give us a wonderful opportunity to understand more about a lot of issues, lung issues in particular, that were a focus of the fire department for decades. But this morning, I'm going to talk to you about our recent cancer work. And as Roberto told you, because it's known that toxins were present at the World Trade Center site, we at FDNY were interested in looking at cancer rates in first responders soon after 9/11. In 2011, we published the first major study of post-9/11 cancer and reported that cancer risk was up to 10% higher in New York City FDNY firefighters versus other US males. In a more recent study, we compared cancer rates in New York firefighters, FDNY, to cancer rates in firefighters who worked in other major US cities.

In this last recent study, we found no overall difference in cancer rates between the two firefighter groups, the New York firefighters versus those from the other major cities. However, there were some differences in specific cancers, both higher and lower. We found higher prostate and higher thyroid cancer rates and lower lung cancer rates in FDNY compared to the other firefighters. Both our original FDNY study from 2011 and the firefighter comparison study, which was published more recently, from cities outside of New York found small overall differences in cancer rates when compared to the US male population. Therefore, we can't yet conclude that the increase in cancer that we observed in our 2011 study in the New York firefighters was due solely to 9/11 exposure, as it might also be due to the hazards of firefighting itself.

We continue to update registry information from various states, 10 or 11 states where some of our firefighters have retired to, so we continue to update both the FDNY data and the data from the other major cities. And also, just to let you know, that the average latency between smoking and lung cancer is about 30 years, and also cancer risk increases with increasing age. Therefore, our current studies will follow people far into the future in order to get the most comprehensive picture of the health consequences of the 9/11 tragedy.

As for now, we recommend that you continue to come for screening to identify cancers at a stage that treatment is most likely to be successful and that the World Trade Center Health Program currently includes the following screening tests: colonoscopy, chest CT scans, mammography, Pap smears, and annual blood tests including blood cell counts which can be useful for hematologic or blood malignancies. And we thank you for your attention and really thank NIOSH very much for putting this together and for their continued support of our program.

Study Fact Sheet
Post-9/11 Cancer Incidence in FDNY Firefighters

Potential Impact: We believe that not enough time has passed since 9/11 to understand the relationship between World Trade Center (WTC) exposure and cancer. For example, average latency between smoking and lung cancer is 30 years.

Research: All three groups of rescue/recovery workers (FDNY, the NYCDOH Registry and Mount Sinai Health Consortium) reported small increases in overall cancer rates in persons who worked at the WTC in comparison with the general US population.

Population: FDNY firefighters who responded to the WTC disasters.

Findings: Our earlier research found that risk of all cancers among WTC-exposed male firefighters was up to 10% higher than US male population. A more recent study compared overall cancer rates in FDNY firefighters to cancer rates in firefighters who did not work at the WTC.

This study found that:

  • Overall cancer rates were similar between both groups of firefighters.
  • Thyroid and prostate cancers were higher in FDNY men.
  • Lung cancer was lower.

Maintain Good Health:

  • Stop tobacco smoking.
  • Continue routine screening to identify cancers at a stage when treatment is most likely to be successful
    • The WTC Health Program includes the following screening tests
      • Colonoscopy
      • Chest CT scans
      • Mammography
      • Pap smears
      • Annual blood tests including cell blood counts
Incidencia del cáncer después del 9/11 en los bomberos del FDNY

Impacto potencial: Creemos que no ha pasado suficiente tiempo desde el 9/11 para comprender la relación entre las exposiciones ocurridas en el World Trade Center (WTC) y el cáncer. Por ejemplo, la latencia promedio entre fumar y el cáncer de pulmón es de 30 años.

Investigación: Los tres grupos de trabajadores de rescate y recuperación (FDNY, el Registro de NYCDOH y el Consorcio de Salud de Mount Sinai) reportaron leves aumentos en las tasas globales de cáncer en las personas que trabajaron en el WTC, en comparación con la población general de los EE. UU.

Población: Bomberos del FDNY que respondieron a los desastres del WTC.

Hallazgos: Nuestra investigación anterior halló que el riesgo de todo tipo de cáncer en los bomberos de sexo masculino expuestos a los eventos del WTC fue de hasta un 10 % mayor que el de la población masculina de los EE. UU. Un estudio más reciente comparó las tasas globales de cáncer en los bomberos del FDNY con las tasas de cáncer en bomberos que no trabajaron en el WTC.

Este estudio halló lo siguiente:

  • Las tasas globales de cáncer fueron similares entre ambos grupos de bomberos.
  • La cantidad de casos de cáncer de tiroides y de próstata fue más alta en los hombres del FDNY.
  • El cantidad de casos de cáncer de pulmón fue más baja.

Mantenga su salud en buen estado:

  • Deje de fumar tabaco.
  • Continúe los exámenes de rutina para identificar los cánceres en una etapa en la que el tratamiento tenga más probabilidades de surtir efecto.
    • El Programa de Atención Médica del WTC incluye las siguientes pruebas de detección:
      • Colonoscopia
      • Tomografía computarizada de tórax
      • Mamografía
      • Prueba de Papanicoláu
      • Análisis de sangre anual que incluye un hemograma
Częstość występowania raka po ataku 9/11 u strażaków FDNY

Potencjalny wpływ: Naszym zdaniem od ataku 9/11 nie minęło wystarczająco dużo czasu, aby możliwe było zrozumienie związku między ekspozycją World Trade Center (WTC) i zachorowalnością na raka. Na przykład średni okres utajenia między paleniem a zachorowaniem na raka płuc, wynosi 30 lat.

Badanie: Wszystkie trzy grupy pracowników biorących udział w akcji ratowniczej (FDNY, Rejestr NYCDOH i Konsorcjum ds. Zdrowia Mount Sinai) zgłaszały niewielki wzrost zachorowalności na nowotwory u osób, które pracowały przy WTC w porównaniu do ogólnej populacji Stanów Zjednoczonych.

Populacja: Strażacy FDNY, którzy brali udział w akcji ratowniczej WTC.

Ustalenia: Dotychczasowe badania wykazały, że ryzyko zachorowania na wszystkie typy nowotworów wśród strażaków narażonych na ekspozycję WTC było do 10% wyższe niż w populacji mężczyzn w USA. Nowsze badania porównały ogólną zachorowalność na raka u strażaków FDNY do zachorowalności na raka u strażaków, którzy nie pracowali przy WTC.

Badanie wykazało, że:

  • Ogólnie zachorowalność na raka była zbliżona w obu grupach strażaków.
  • Zachorowalność na raka tarczycy i prostaty była wyższa u mężczyzn z FDNY.
  • Zachorowalność na raka płuc była niższa.

Dbaj o zachowanie dobrego stanu zdrowia:

  • Rzuć palenie.
  • Wykonuj rutynowe badania przesiewowe, aby wykryć nowotwór na etapie, gdy leczenie najprawdopodobniej zakończy się sukcesem
    • Program Ochrony Zdrowia WTC obejmuje następujące badania przesiewowe:
      • Kolonoskopia
      • Tomografia komputerowa klatki piersiowej
      • Mammografia
      • Badanie cytologiczne
      • Coroczne badania krwi, w tym morfologia
FDNY 消防隊員中的 9/11 事件 後癌症發病率

潛在影響: 我們認為,自 9/11 事件以來沒有足夠的時間瞭解世界貿易中 心 (WTC) 暴露與癌症之間的關聯。 例如,吸菸與肺癌的平均潛伏期是 30 年。

研究: 全部三組救援/復原工作者(FDNY、NYCDOH 登記系統和西奈山醫療聯盟)報告,在 WTC 工作的人員的總體癌症發病率與美國一般人群相比有小幅增加。

人群: 對 WTC 爆炸案進行救援的 FDNY 消防隊員。

研究結果: 我們之前的研究發現,暴露於 WTC 的男性消防員的所有癌症風險比美國男性高出10%。最近的一項研究針對 FDNY 消防員整體癌症發病率和沒有在 WTC 工作的消防員癌症發病率進行比較。


  • 兩組消防員的整體癌症發生率相似。
  • 甲狀腺和前列腺癌在 FDNY 男性中較高。
  • 肺癌較低


  • 戒菸。
  • 在治療最有可能成功的階段,繼續進行例行性篩檢以鑑別癌症
    • WTC 健康計劃包括以下篩檢測試
      • 結腸鏡檢查
      • 胸部 CT 掃描
      • 乳房 X 光檢查
      • 子宮頸抹片檢查
      • 年度血液檢查,包括血細胞計數

Effects of WTC Exposure in Adolescent Lung and Heart Health
Leonardo Trasande, MD
Associate Professor, Department of Pediatrics; Associate Professor, Department of Environmental Medicine; Associate Professor, Department of Population Health, New York University

To enable sound, click the speaker icon in the lower right of the video after starting the video.

Dr. Trasande: Thank you, Jackie, for the warm introduction. Thank you to NIOSH and the organizers. I'm delighted to be here. There were tens of thousands of children who lived or attended school, depending upon how you define Lower Manhattan, on September 11 and in the weeks and months that followed. And as Jackie described, there are some substantial gaps in our knowledge with respect to what the effects of that early life exposure were and the implications now 10-15 years later. In many cases, these are now young adults as well as adolescents. And I'd like to draw some emphasis in particular on two aspects where there are some gaps in our knowledge, and one is in the impact of the chemicals that were in the dust cloud and in the dust and the fires that went on, in some cases, for months after the disaster. We had a substantial amount of research already accumulated with time looking at the psychosocial effects or the mental health effects of World Trade Center-related exposure, the trauma in these children. That’s actually quite, maybe not optimally described, but quite well described. And Jackie described, there have been studies in pregnant women and the children recently born showing effects, but it's the early life exposures in childhood where our knowledge is arguably the most thin.

Now, the World Trade Center Health Registry, which Dr. Brackbill will describe in greater detail in a few minutes, documented the first warning signal in this regard, looking in particular at the development of asthma in children who were exposed to the disaster, and they found substantial, really frightening rates of asthma after 9/11 in the youngest children at the time of the disaster, that is, children less than five. We had the privilege of working with Dr. Reibman and colleagues, leveraging the clinically-referred population of children who came for health concerns related to 9/11 at Bellevue, and found some interesting and, unfortunately, concerning findings supporting effects as well potentially on lung function in the children who were exposed, but also with a clustering of cardiovascular-related or heart health-related risks.

In particular, we found a relatively high rate of children with elevated blood pressure and a pattern in which their lipid levels were a little bit distorted in a way that could herald the later life consequences for cardiovascular health. So that prompted us to seek funding from the Centers for Disease Control and Prevention to look at two populations together. I mean, when you're talking ten years out after the disaster and you haven't followed a population carefully every year or two years in the interceding period, you have the quandary that, the more you go out, the more there can be other factors that might explain the associations that you might have been able to control for or rule out if you had followed the population more carefully over time. So we recruited a population of young adults and adolescents from the World Trade Center Health Registry and we matched that population to a population of young adults and children who were New York City residents as well, but were not in the eligibility zone for the World Trade Center Health Registry, so they would be a reasonable comparison group for relatively less exposure. And I'll say more about why I mean relatively less as opposed to no exposure in a moment.

We haven't published all the findings as yet. I'll give a preview, to some extent, of those findings, but I'll emphasize the findings we have so far. We performed a battery of tests over about two to three hours, looking at lung function as well as measures of blood pressure and stiffness of the arteries, both in the arms and also deeper in the arteries near the heart. And the good news is that we're not seeing as much of the differences in direct lung function that we saw when we looked at a similar population that was clinically-referred. Now, we are seeing a persistence in asthma some 15 years out at a higher rate in the exposed population and in relationship to the dust cloud exposure in children who were exposed in early life. But moving on to the heart health risks, what we've not seen are substantial differences, in relationship to dust cloud exposure or even traumatic exposures, to direct measures of heart health, that is, elevations in blood pressure or measurements of the stiffness of the arteries.

So that, in a way, is good news and reassuring for folks who are rightly concerned and maybe even scared about the implications in later life. Now, what we've also done is to try to get at the chemical exposures in greater detail. I mean, we're dealing with the reality that, in some cases, the recall of parents and children, even if it was based on the World Trade Center Health Registry, can be a difficulty. And insofar as you're imprecise about your exposure, it's harder to really identify effects that are really there. So what we've been able to do is actually leverage measurements of chemicals that were found in the dust in the serum of the these children, two types of chemicals in particular.

We're focusing on Teflon-like chemicals and dioxins, the chemicals that are emitted through burning of various materials that occurred in the months and years that followed. And we have found some striking differences in the Teflon-like chemicals, and when we look at the chemical exposure as the marker of exposure, as opposed to the self-report description of exposure, we do start to see some associations, in particular with elevations in cholesterol and lipid levels, that may be a signal for future health risks down the line. So this reinforces both the need for ongoing medical monitoring and care, but also the need for further research to continue, to follow-up in this population.

Now, I'll close by going back to what Jackie described before having me come up, and that is that there were some early effects in prenatally-exposed children, and to some extent we've actually not heard much from that population. And so I have the privilege of working with partners at Columbia Mailman School of Public Health to leverage two existing cohorts where one was recruited for another reason, so didn’t have as much substantial 9/11 exposure, and then a population that was specifically followed with the intent of getting a population of women and children who were exposed, to get that kind of comparison, and that population is now about 15 years of age.

So what we're doing is to not only leverage the existing data on their body mass and their growth as well as measurement of their cognitive function, but also bringing them in to evaluate their heart health. And that may actually be where we find an even stronger signal, because prenatal and early life exposures may be a time window of even more unique vulnerability. So in that regard, I have to tell you stay tuned because we've just had the privilege of receiving the funding to get started with that work. So again, thank you for the opportunity. We look forward to your questions and comments as the panel moves on. Thank you.

Study Fact Sheet
Effects of WTC Exposure in Adolescent Lung and Heart Health

Research: Children are uniquely vulnerable to the effects of environmental contaminants, including those released through disasters. We examined effects of World Trade Center exposure on lung and heart health by comparing adolescents in the World Trade Center Health Registry (WTCHR) who were exposed in the first eight years of life to a matched comparison group.

We successfully recruited 225 comparison adolescents and 183 WTCHR participants. The two populations were slightly more female but similar in race/ ethnicity and age distribution. Given that both populations were NYC residents and that exposure to traumatic events was widespread in NYC in the aftermath of the disaster, the comparison group was not a purely unexposed group, and so we compared groups by their participation in the WTCHR and by exposure to dust and trauma.

We confirmed findings from previous groups documenting increases in asthma after September 11, 2001 in the WTCHR group and in relationship to exposure, but did not find differences in lung function. We also were unable to detect significant differences in arterial stiffness, lipid levels or insulin resistance.

However, biomarkers of chemical exposures such as perfluorinated compounds (PFCs) and dioxins may also be more indicative of exposure and effect, and was the focus of a subsequent cooperative agreement funded by NIOSH. Indeed, we identified substantially higher levels of PFCs in WTCHR and dust-exposed children, as well as increases in cholesterol levels in direct relationship to PFC levels. PFCs were not related to other cardiovascular endpoints, and analyses of dioxins and cardiovascular endpoints are forthcoming.

These data also raise the question whether effects of earlier – prenatal – exposure may be equally or more problematic. In a newer project we are leveraging two unique and contemporaneous cohorts to examine chemical and psychosocial stressors in relationship to proximity to the WTC site and self-reported exposures, and evaluating birth, neurodevelopment and cardiometabolic outcomes.

Efectos de la exposición relacionada con el WTC en la salud cardiaca y pulmonar de adolescentes

Investigación: Los niños son particularmente vulnerables a los efectos de los contaminantes ambientales, como aquellos que se liberan cuando ocurren desastres. Se exploraron los efectos en la salud cardiaca y pulmonar de la exposición relacionada con el WTC, al comparar a adolescentes inscritos en el Registro de Salud del World Trade Center (WTCHR) —que estuvieron expuestos antes de cumplir los 8 años de edad— con un grupo de comparación equiparado.

Se consiguió reclutar a 225 adolescentes para el grupo de comparación y a 183 participantes del WTCHR. Las dos poblaciones tuvieron una cantidad levemente mayor de mujeres, pero fueron similares en raza/etnicidad y distribución de edad. Debido a que ambas poblaciones eran residentes de NYC y que la exposición a eventos traumáticos después del desastre fue generalizada en toda la ciudad, el grupo de comparación no fue un grupo totalmente libre de exposiciones; por ese motivo, comparamos a los grupos por su participación en el WTCHR y por su exposición al polvo y trauma.

En el grupo del WTCHR se confirmaron los hallazgos obtenidos de dos grupos previos en los que se documentó un aumento en la cantidad de casos de asma después del 11 de septiembre del 2001 y en relación con la exposición, pero no se encontraron diferencias en cuanto a la función pulmonar. Tampoco se pudieron detectar diferencias significativas en la rigidez arterial, los niveles de lípidos o la resistencia a la insulina.

Sin embargo, los biomarcadores de las exposiciones químicas, como los compuestos perfluorados (PFC, por sus siglas en inglés) y las dioxinas, también podrían ser más indicativos de exposición y efecto, y fueron el centro de un acuerdo cooperativo subsecuente financiado por NIOSH. De hecho, se identificaron niveles considerablemente más altos de PFC en niños del WTCHR y niños que estuvieron expuestos al polvo, como también un aumento en los niveles de colesterol en relación directa con los niveles de PFC. Los PFC no estuvieron relacionados con otros criterios de valoración cardiacos, y el análisis de estos criterios y de las dioxinas está pendiente.

Estos datos también hacen plantear la pregunta respecto a si los efectos dela exposición temprana —prenatal— podrían ser igual de problemáticos o más problemáticos. En un proyecto más nuevo estamos usando dos cohortes únicas y contemporáneas para examinar los factores estresantes de orden químico y sicosocial con relación a la proximidad al sitio del WTC y las exposiciones autoreportadas, y evaluar los criterios de valoración de nacimiento, desarrollo neurológico y cardiometabólicos.

Skutki ekspozycji WTC w Chorobach płuc i serca u młodzieży

Badanie: Dzieci są wyjątkowo podatne na skutki zanieczyszczeń środowiskowych, w tym tych, uwalnianych na skutek katastrof. Zbadaliśmy skutki ekspozycji podczas ataku na World Trade Center dla zdrowia płuc i serca, poprzez porównanie młodzieży z Rejestru Medycznego World Trade Center (WTCHR), która była narażona na ekspozycję w pierwszych ośmiu latach życia, z odpowiednią grupą porównawczą.

Pomyślnie włączyliśmy do badania 225 osób z grupy porównawczej oraz 183 członków WTCHR. W obu grupach znalazło się nieco więcej kobiet, ale rozkład wieku i ras/pochodzenia etnicznego był podobny. Zważywszy, że obie populacje to mieszkańcy NYC oraz że ekspozycja na traumatyczne przeżycia była szeroko rozpowszechniona w NYC w następstwie katastrofy, grupa porównawcza nie była zupełnie nienarażona na ekspozycję, dlatego porównaliśmy obie grupy pod względem przynależności do WTCHR oraz ekspozycji na pył i urazy.

Potwierdziliśmy ustalenia uzyskane dla wcześniejszych grup, dokumentujące wzrost zachorowalności na astmę po 11 września 2001 r. w grupie WTCHR oraz w powiązaniu z ekspozycją, ale nie odkryliśmy różnic w funkcjonowaniu płuc. Nie byliśmy również w stanie wykryć istotnych różnic w sztywności tętnic, poziomach lipidów czy insulinooporności.

ednak biomarkery ekspozycji na substancje chemiczne, takie jak związki perfluorowane (PFC) i dioksyny, mogą również bardziej wskazywać na ekspozycję i jej skutki. Ta kwestia była tematem kolejnego porozumienia o współpracy, finansowanego przez NIOSH. Rzeczywiście, zidentyfikowaliśmy znacznie wyższe poziomy PFC u członków WTCHR i dzieci narażonych na ekspozycję na pył, a ponadto zwiększenie stężenia cholesterolu, związane bezpośrednio z poziomem PFC. Poziomy PFC nie były powiązane z innymi problemami układu sercowo-naczyniowego, a analizy powiązania dioksyn z układem sercowo-naczyniowym są w przygotowaniu.

Dane te również podnoszą pytanie, czy skutki wcześniejszej – prenatalnej – ekspozycji mogą być równie lub bardziej problematyczne. W nowszym projekcie wykorzystaliśmy dwie unikalne i współczesne kohorty do zbadania chemicznych i psychospołecznych czynników stresogennych w powiązaniu z odległością od terenu WTC i samodzielnie zgłaszanych ekspozycji, oceniając wyniki badań po urodzeniu oraz wyniki neurorozwojowe i kardiometaboliczne.

WTC 暴露對於青春期肺和心 臟健康的影響

研究: 兒童特別容易受到環境污染物的影響,包括通過災害釋放的環境污染物。我們透過比較世界貿易中心"健康狀況登記系統" (WTCHR) 在 8 歲前暴露的青少年與匹配的對照組,檢測了世界貿易中心暴露對肺和心臟健康的影響。

我們成功招募了 225 名對照青少年和 183 名 WTCHR 參與者。 這兩個 人群的女性稍多一點,但在種族和年齡分佈上却相似。鑑於這兩個人群都是紐約市居民,爆炸案發生後廣泛暴露於紐約市的創傷性事件,對照組不是一個純粹的未暴露組, 因此,透過他們參加 WTCHR 以及暴露於灰塵和創傷,對兩組進行比較。

我們證實了以前的研究結果,記錄了 WTCHR 組在 2001 年 9 月 11 日之後的哮喘的增加情況以及與暴露的關係,但沒有發現肺功能的差異。我們也無法檢測到動脈僵硬度、血脂水平或胰島素抗性的顯著差異。

然而,全氟化合物 (PFC) 和二噁英等化學品暴露的生物標誌物也可能是暴露和影響的更為明顯的指標, 也是 NIOSH 資助的後續合作協議的重點。事實上,我們發現暴露於 WTCHR 和灰塵的兒童的全氟化合物含量明顯較高,膽固醇水平與 PFC 水平直接相關。PFC 與其他心血管終點無關,即將進行二噁英和心血管終點分析。

這些數據也提出了較早 - 產前 - 暴露的影響是否可能同等或更高的問題。在一個較新的項目中,我們利用兩個獨特和同期的小組研究化學和社會心理壓力與臨近 WTC 點和自我報告暴露的關係,並且評估出生、神經發育和心臟代謝結果。


Findings of the WTC Health Registry
Robert Brackbill, PhD, MPH (presenting on behalf of Mark Farfel, ScD)
Director, World Trade Center Health Registry, New York City Department of Health

To enable sound, click the speaker icon in the lower right of the video after starting the video.

Dr. Brackbill: Many times when people come and begin working at the Registry, I’m the one who sits down and tells the history. So I have to kind of be careful not to start, “October 2001…” blah blah blah, but anyway. So, and I’m glad that Dr. Moline mentioned ATSDR because I was going to thank NIOSH for bringing us here, putting together this program, but it was the Agency for Toxic Substances and Disease Registry which found a way to fund the Registry back in July 2002.

And I want to say that I am here for Dr. Mark Farfel, who has unfortunately picked up something from his son and has to stay home sick today. He is a person who has made the Registry into a more customer service-oriented type of thing. He would talk about the Treatment Referral Program, which has been very involved with the World Trade Center Health Program and helping them get people enrolled and put their applications in. So one of the first things that we do when we talk about the Registry to the public is we try to say what the Registry isn’t and what the Registry is. The Registry is the largest post-disaster registry in US history, and now one of the longest-running in the world. It was launched 2002, as I mentioned, July 2002 it was funded, and it is housed in the New York City Department of Health and Mental Hygiene.

It is the mission of the Registry to understand the short- and long-term physical and mental health consequences of 9/11. We do this by tracking the health of 71,000 people exposed to the disaster. I just was thinking that 71,000 is more people than where I’m from, Harrisburg, Pennsylvania, which is like 55,000. And I was thinking about what stadium—is like Penn State stadium big enough to have 71,000 people? I don’t know. Is there anything around here? Seventy-one thousand people, it’s a lot, you know, and they’ve been like participating in this thing is just so important. I mean, it’s just a public health enterprise of this very important magnitude for understanding the long-term effects of 9/11.

Additionally, we collaborate with the World Trade Center Health Program and other researchers and share our findings to help inform the Health Program’s policies. We are also planning for future disasters. And actually that was one of the aims of the Registry was in terms of understanding how to respond to disasters, even weather disasters such as hurricanes and that sort of thing. We actually periodically get calls from people to help with putting a registry together after some event.

Who makes up the 71,000 people we call enrollees? These are people who voluntarily enrolled in the Registry in 2003-2004 and completed our first major health survey. So that enrolment took place from September 2003 to November 2004, so it was about an 18-month period that we, through various media campaigns and acquiring lists of people from different organizations, including Red Cross and that sort of thing, volunteers of the Red Cross or Salvation Army, lists that we tried to find people and call them up, and go through a consent and then get them enrolled on the Registry.

They were exposed to 9/11 but didn’t have to be sick to be eligible for enrolment. Now, that’s a very important thing when you establish a registry. You need to have the full cross-section of people who are not only sick but those who are healthy and remain healthy through the whole time that you have a registry. Having those sick and healthy people helps us get a fuller picture of the types and course of 9/11 health impacts.

Now this group on the Registry includes rescue recovery workers, survivors who lived, worked or went to school in Lower Manhattan, including children, tower survivors and Spanish- and Chinese-speakers, and also Polish actually. We found many Polish construction workers too who enrolled on the Registry. They live in all 50 states and more than 15 countries. I mentioned that we have looked at—I’m not sure, I think we have somebody from every congressional district in the United States who is on the Registry, and I think that just showed it’s a national registry, you know. And an international registry because we had people who were working in the towers who were from Canada, Great Britain, throughout Europe, Middle East, and those people are also on the Registry as well. We don’t have many but there are some.

The Registry was closed for enrolment in 2004, and that’s an important thing that it’s a cohort. It’s a closed cohort. We often get asked whether or not you can get on the Registry, enroll on it, but because it’s a closed cohort for epidemiological purposes, to observe people over a period of time, you need to close it and then follow those same people for all the years afterward. But our findings are also relevant to others who are not in the Registry. That’s an important point.

How many health surveys have we conducted? Well, we've actually, since enrolment, we've conducted three follow-up surveys. One we conducted, in the first one; Wave 2 we refer to as 2005-2006; the third follow-up survey in 2010-2011; and then most recently we had a fourth, 2015-2016. And each time we do a survey, we asked slightly different questions. We have some questions we ask every time such as questions on mental health, Post-Traumatic Stress Disorder for instance. We ask about symptoms in every survey. But then we also introduce new questions as time goes on, as we learn. We want to learn about other things.

The Registry does not provide clinical care but as I mentioned earlier, we do have a program where we try to help people get into treatment and get an application, and give them resources, information to do that. We do connect enrollees with the World Trade Center Health Program for monitoring and treatment, as I just said. Our Treatment Referral Team reaches out to thousands of enrollees who reported 9/11-related symptoms and conditions on our surveys. We encourage them to apply to the Health Program and offer help as needed.

Okay, now the findings. Cancer and respiratory findings—well, the Registry has published over 80 papers, and I think that’s more, close to about 90 now, covering various findings. Summaries can be found on the website. You can go to our website. It’s easy, just World Trade Center Health Registry, it will pop up and you can see up the top, Publications. With regard to cancer, the Registry has similar findings to responder and survivors. We also heard from Dr. Reibman and others about responders and how findings suggest that persistent lower respiratory symptoms may be due to injury of the small airways in the lungs. And we also have a collaborative respiratory study which she mentioned earlier that also looked at area workers and residents and reported ongoing lower respiratory symptoms on other registry surveys, but risk of having persistent symptoms with reported intense exposure to dust cloud. Dust cloud also remains an important exposure. Risk also increased with reported thickness of dust in the home or workplace. We've also followed up these participants about four or five years later to determine if they continued to have the same lower respiratory symptoms. The good news is that people in the study were largely improving as a group, although some continue to have lower respiratory symptoms, particularly those with Post-Traumatic Stress Disorder.

It is common for respiratory illness and mental health conditions to occur together in responders or area workers and residents. For instance, we found that 1 in 4 of the area workers and residents and passers-by, whom have either lower respiratory symptoms or Post-Traumatic Stress Disorder symptoms, had both conditions five or six years after 9/11. We also looked at asthma, where we found an increase in asthma among enrollees in the first two years after 9/11. We found that about 1 in 3 participants with asthma had well-controlled symptoms a full decade after the attacks. Having cooccurring conditions such as PTSD or sleep apnea contributed to poor asthma control.

Children also experienced similar outcomes such as persistent symptoms, but then we also found poor asthma control among children. That was related actually to PTSD in their parents. Some also had a combination of respiratory and mental health symptoms and conditions. One of the hallmarks of 9/11 health impacts is that it’s not unusual for survivors and responders to have more than one physical health condition or a combination of mental and physical health conditions related to 9/11. Furthermore, having more than one condition generally has a greater impact on quality of life than any one condition alone. That’s an important thing I think we’re finding as the years go on, that there is comorbidity, that people have a combination of physical health and mental health and they exacerbate each other.

For the future, we plan to continue tracking health enrollees for years to come, under the Zadroga Act, including cancer and PTSD, and potential emerging conditions such as autoimmune conditions. We will keep you informed of our findings even as we continue to work with our colleagues in the World Trade Center Health Program to build a bigger picture of 9/11 health impacts and ways to address them. Thank you.

Study Fact Sheet
Findings of the WTC Health Registry

Potential Impact: The WTC Health Registry, based in the NYC Dept. of Health, tracks the physical and mental health of 71,000 people directly exposed to the 9/11 Word Trade Center disaster. During 2003-2004 people could chose to enroll in the Registry and complete a baseline health survey. Since then, findings from the Registry have been in more than 80 publications, which has helped improve health care and inform the public about 9/11 health. Our findings also help with planning and response for future emergencies. Finally, the Registry helps spread the word about the WTC Health Program (which is a different program from the Registry). Since 2013, the Registry’s Treatment Referral Program has reached nearly 23,000 people and helped almost 10,000 apply for the WTC Health Program.

Research: The Registry has done three follow-up health surveys and several in-depth studies to understand 9/11 health impacts and new 9/11 conditions. We also work with WTC Health Program doctors and researchers. The Registry does not provide direct health care, but we support members by helping them get care for 9/11-conditions through the WTC Health Program. Population Members of the Registry live in every state and more than 15 countries. They include rescue/ recovery workers and volunteers, passers-by, and people who lived, worked or went school in Lower Manhattan, including tower survivors, pregnant women and children.

Findings: Our findings show that the 9/11 disaster has had short and long-term harmful impacts on physical and mental health, quality of life and how people function. The most common health outcomes are PTSD, depression, asthma and heartburn/ reflux. Many people have more than one mental health or physical health condition or a mix of both. For example, PTSD often occurs with depression and with asthma. Children had the same types of health outcomes as adults. To learn more about Registry findings visit

Hallazgos del Registro de Salud del WTC

Impacto potencial: El Registro de Salud del WTC, con sede en el Departamento de Salud de NYC, monitorea la salud física y mental de 71 000 personas que estuvieron directamente expuestas al desastre del 9/11 en el Word Trade Center. Durante los años 2003-2004, las personas tuvieron la opción de inscribirse en el Registro y completar una encuesta de referencia sobre su estado de salud. Desde entonces, los hallazgos derivados del Registro se han incluido en más de 80 publicaciones, lo cual ha ayudado a mejorar la atención médica y a informar al público sobre temas de salud relacionados con el 9/11. Nuestros hallazgos también sirven de ayuda para la planificación y respuesta a emergencias futuras. Por último, el Registro contribuye a difundir información sobre el Programa de Atención Médica del WTC (el cual es un programa diferente al del Registro). Desde el 2013, el Programa de Remisión a Tratamiento del Registro ha llegado a cerca de 23 000 personas y ayudado a casi 10 000 a solicitar la inscripción en el Programa de Atención Médica del WTC.

Investigación: El Registro ha hecho tres encuestas de seguimiento sobre la salud y varios estudios detallados para comprender el impacto del 9/11 en la salud y las afecciones nuevas relacionadas con este evento. También trabajamos con médicos e investigadores del Programa de Atención Médica del WTC. El Registro no provee atención médica directa. Sin embargo, ayudamos a los miembros a conseguirla para sus afecciones relacionadas con el 9/11 a través del Programa de Atención Médica del WTC.

Los miembros del Registro viven en todos los estados y en más de 15 países. Incluyen a trabajadores y voluntarios que participaron en tareas de rescate y recuperación, transeúntes y personas que vivían, trabajaban o asistían a centros educativos en el Bajo Manhattan, como los sobrevivientes de las torres, mujeres embarazadas y niños.

Hallazgos: Nuestros hallazgos muestran que el desastre del 9/11 ha tenido efectos a corto y largo plazo sobre la salud física y mental, la calidad de vida y la forma de funcionar de las personas. Las resultados más comunes en la salud son el TEPT, la depresión, el asma y la acidez o reflujo estomacal. Muchas personas tienen más de una afección física o mental, o una combinación de ambas. Por ejemplo, el TEPT con frecuencia se da con depresión y con asma. Los niños tuvieron los mismos tipos de consecuencias para la salud que los adultos. Para saber más sobre los hallazgos del Registro, visite la página

Ustalenia uzyskane na podstawie Rejestru Medycznego WTC

Potencjalny wpływ: Rejestr Medyczny WTC, z siedzibą w Nowojorskim Departamencie Zdrowia, monitoruje stan zdrowia fizycznego i psychicznego 71 tys. osób, które zostały bezpośrednio narażone na ekspozycję po ataku na World Trade Center 9/11. W latach 2003-2004 pacjenci mieli możliwość zapisania się do Rejestru i przejścia podstawowych badań. Od tego czasu ustalenia uzyskane na podstawie Rejestru zamieszczono w ponad 80 publikacjach, które pomogły poprawić poziom opieki zdrowotnej i poinformować opinię publiczną o skutkach zdrowotnych związanych z 9/11. Nasze ustalenia pomagają również planować i reagować na sytuacje wyjątkowe w przyszłości. I wreszcie – Rejestr pomaga w rozpowszechnianiu informacji na temat Programu Ochrony Zdrowia WTC (który jest odrębny od programu prowadzonego w ramach Rejestru). Od 2013 roku Program Skierowań na Leczenie, działający w ramach Rejestru, osiągnął liczbę prawie 23 tys. członków i pomógł niemal 10 tys. zgłosić się do Programu Ochrony Zdrowia WTC.

Badanie: W ramach Rejestru prowadzimy trzy badania kontrolne i kilka badań szczegółowych, które mają na celu poznanie wpływu wydarzeń 9/11 na zdrowie oraz nowych jednostek chorobowych powiązanych z 9/11. Współpracujemy również z lekarzami i naukowcami z Programu Ochrony Zdrowia WTC. W ramach Rejestru nie świadczymy usług bezpośredniej opieki zdrowotnej, ale w przypadku chorób związanych z 9/11 pomagamy członkom uzyskać taką pomoc za pośrednictwem Programu Ochrony Zdrowia WTC.

Członkowie populacji Rejestru mieszkają w każdym stanie oraz w ponad 15 krajach. Są to zarówno pracownicy i wolontariusze pracujący przy akcji ratunkowej, jak i przechodnie i ludzie, którzy mieszkali, pracowali lub uczęszczali do szkół na Dolnym Manhattanie, a także osoby ocalałe z wieżowców, kobiety w ciąży i dzieci.

Ustalenia: Nasze ustalenia pokazują, że katastrofa 9/11 miała krótko- i długoterminowy, szkodliwy wpływ na zdrowie fizyczne i psychiczne, jakość życia i funkcjonowanie ludzi. Najczęstszymi problemami zdrowotnymi są PTSD, depresja, astma i zgaga/refluks. Wiele osób cierpi na więcej niż jedną jednostkę chorobową z zakresu zdrowia psychicznego lub fizycznego lub też na kombinację obu. Na przykład PTSD występuje często z depresją i astmą. U dzieci zauważono te same problemy zdrowotne, co u dorosłych. Aby dowiedzieć się więcej na temat ustaleń dokonanych na podstawie Rejestru, odwiedź stronę

世界貿易中心 (WTC) 健康狀況 登記系統研究結果

潛在影響: 基於紐約市衛生局的 WTC 健康狀況登記系統跟進了直接 暴露於 9/11 世界貿易中心爆炸案的 71,000 人的身心健康狀況。在 2003 - 2004 年期間,人們可以選擇在登記 系統登記並完成基線健康調查。自那 以後,登記系統的研究結果已發表在 80 多份出版物上,已幫助改善了醫 療保健,並向公眾宣傳 9/11 健康資 訊。我們的研究結果也有助於規劃和 應對未來的緊急情況。 最後,登記 系統幫助傳播 WTC 健康計劃(這是 與登記系統不同的計劃)。自 2013 年以來,登記系統的治療轉診計劃已 達近 23,000 人,並幫助將近 10,000 人申請 WTC 健康計劃。

研究: 為了解 9/11 健康影響和 9/11 新病症,本登記系統進行了三次後續 健康調查和幾項深入研究。 我們還 與 WTC 健康計劃的醫生和研究人員 合作。登記系統不提供直接的醫療保 健,但我們透過 WTC 健康計劃讓他 們的 9/11 病症得到照護,從而支持 會員。

登記系統的人口會員來自各個州和 15 多個國家。他們包括救援/復原工 作者和志願者、路人、以及在曼哈頓 下城生活、工作或上學的人,包括大 樓倖存者、孕婦和兒童。

研究結果: 我們的研究結果顯 示,9/11 事件對身心健康、生活質 量和人們的行為方式產生了短期和 長期的有害影響。最常見的健康結 果是 PTSD、抑鬱症、哮喘和胃灼 熱/反流。許多人有一種以上的精神 健康或身體健康問題或兩者兼有。 例如,PTSD 經常伴有抑鬱症和哮 喘。 兒童與成年人具有相同類型的 健康結果。 如需瞭解更多有關登 記系統的研究結果的資訊,請造訪


Panel 2

Diseases Existing Together (Co-morbidity)
Sean Clouston, PhD
Assistant Professor, Department of Family, Population, and Preventive Medicine, Stony Brook University

To enable sound, click the speaker icon in the lower right of the video after starting the video.

Dr. Clouston: All right, yes. So, maybe it’s worthwhile thinking about where we start. None of you are scientists so I’m trying to make this a little bit lively. At Stony Brook, we've had this really interesting relationship between different investigators and the responders themselves, trying to figure out what's going on for these people.

Mental health is such a huge component of that. Most of our responders have some symptoms. Even if they're not clinical symptoms, there's a little bit of symptoms, and that sort of pervades throughout and we’re going to build on—Robert has talked about comorbidity here a little bit. But I’m going to sort of go backwards and tell you a little bit about my family. So I was raised in a very loving household, but my grandfather was of course at the war and he had chronic PTSD. So as a kid, we were always told not to wake him up because he’s come out and he’d punch you. (Laughs.) Which was sort of always a funny thing, to see someone as both a risk and a source of love.

I think what has happened at Stony Brook is that there has been this relationship, in a similar sort of way—not that similar I guess but there has been this sort of relationship between Evelyn and Ben, who would normally give this talk but he’s currently in London because he just had a grandchild—where they sort of talk about the role of mental health, and we talk about how it gets embodied and how this sort of circularity between mental health and physical health occurs and what it means, right.

And so what has come out of it is that we try to understand why people are reporting having mental health problems, what it means for them, how they internalize it and then of course what does it actually do, right, if anything. So you can sort of see this with maybe not a preliminary but one way that this plays out is through the cough, right. So PTSD is in itself a memory kind of disease, right. It contains flashbacks, it contains nightmares, which are memories of the event that are stressful. And then it contains emotional responses and behavioral responses and difficulties, right.

So, well, what can you think about with the coughing? Well, the coughing is, on the one hand, physical, right? You actually cough. There's a thing. We can see it. We can watch it happen. On the other hand, it’s also mental. It’s a reminder that you were somewhere that you had to cough, and so the cough brings around this sort of reminder of the event and then the reminder of the event of course can cause some coughing.

The thing with mental health is that these comorbidities are often kind of like this; they're non-specific, right, and they kind of get into the medical realm a little bit. So they can cause a misdiagnosis but they can also cause, we think, real disease, okay. So in this discussion at Stony Brook, we have basically taken the view that the mental health is really a) it’s real, we know that; but b) that there's really, people are reporting about something that going wrong for them, right, and therefore we should take their word and try and figure out exactly what's going wrong for them.

Now, one of the things that I think is interesting and certainly gotten us involved in this is that people with mental health problems, they take longer in the clinic, so they're more expensive. We have to talk to them more, so that’s nice, we get to experience that. But they're also more complex patients. So like the cough, they have these physical symptoms and you have to figure out, like what is this? Is this part of the mental health problem? Is this something different? Is it something new? What's going on? And these things can be chronic, right.

Mental health problems are chronic. There are many people with chronic mental health problems in our clinics and so we’re trying to figure this out both on the short term but also—what's happening for you today—but also in the long term, what's going to happen for you, to you or with you for the next twenty years.

So we started with, in our research, that something must be going wrong with these patients. They're reporting a lot of different symptoms. Something has to be happening. So that has led us to a couple of different types of research. Ben is heavily involved in epigenetic research. The idea here is that the mental health is causing some sort of genetic modification as to how your genes are actually regulated and used and expressed in everyday life. So there's transcripting that’s changing, there's the ways that it’s being expressed itself, all right. So we’re focusing on trying to understand that. And we've got, I think, a paper coming out soon on that.

The next component of what we’re trying to do is understand the sort of memory aspects. So about 35-40% of our responders at Stony Brook report having bad memory, and that it’s getting worse. So we started looking into neurological conditions. The interesting thing with neurological conditions is that they can cause a bunch of nonspecific symptoms, right. So PTSD being located in the brain, it’s not a long distance to the brain itself. And then the brain, if it’s dysregulated, can cause all kinds of stuff to happen, often at low levels.

So we started doing cognitive research to figure out are people who are reporting memory problems, are they actually experiencing memory problems. What do those look like? Are they associated with the mental health? Are they associated with exposure? That kind of thing. The other thing we noticed was that a lot of people, as part of, of course, mental health are also reporting being tired a lot. Fatigue is a terribly nonspecific symptom. You get tired for a lot of different reasons. You might be on treatment. You might be…sorry, I’m supposed to look for a yellow light but I realize that I don’t actually know what—my red light is on, all right.

(Technical advice.)

I didn’t know where to look. All right, there you go, okay. So we think that there might be nonspecific changes to physical functioning as well, right. So if you're getting tired, maybe you're also just not walking that fast. Maybe you're not getting up that fast.

The funny thing with this cohort, right, is that people are starting to get older. And the funny thing with age is that, you know, as we all get older, we rack up comorbidities and the mental health component is an important part of that comorbidity. And so what we’re trying to do now is understand how are things changing for people as they get older. How are these comorbidities interacting? And is there something underlying all of that or is it sort of just what’s expected?

Anyway, so I guess the point here that we’re most interested in, and I think it will be reverberated throughout, is this sort of interaction back and forth between the mental health and the physical system, all right?

(Technical problem.)

Study Fact Sheet
Physical and Mental Comorbidities of PTSD in WTC Responders

Potential Impact: Potential Impact: This study brings us closer to understanding how chronic posttraumatic stress disorder (PTSD) might cause lasting changes to the body and mind. Understanding comorbidity (when two diseases are present) can be important when managing care and providing treatment. This study may help to find negative and positive side effects of some treatments, and may also help responders and their caregivers determine what to plan for in their future. Our study may help to get responders to engage in health-beneficial behaviors as they age.

Research: There is a lot of evidence to suggest that what we do throughout our lives ripples out and changes what we can expect to happen later in life. The men and women who responded to the World Trade Center (WTC) events were physically and psychologically battered by their experiences. Some have developed chronic PTSD. We think that PTSD may have impacts on physical health. This research seeks to examine whether PTSD might play some role in harming the body and mind. We also seek to understand what it means to be an aging WTC responder.

Population: We work closely with the men and women who responded to the WTC events of 9/11 and attend monitoring at the Stony Brook University clinics.

Findings: Symptoms of PTSD can increase over time among some responders experiencing aging-related problems. Diagnoses of WTC-related conditions can worsen PTSD symptoms. WTC responders are more likely to have worse memory than others of the same age and sex. We linked chronic PTSD with changes to changes in how cells function at the RNA level. Symptoms of PTSD are often comorbid with symptoms of breathing conditions like cough and acid reflux. PTSD was also linked with changes in personality. PTSD symptoms have had a fairly devastating impact on family functioning for some responders. Some responders with PTSD appear to be walking slower and having more difficulties getting out of a chair, which may continue to get worse as people get older.

Comorbilidades físicas y mentales del trastorno de estrés postraumático en el personal de respuesta del WTC

Impacto potencial: Este estudio nos permite estar más cerca de comprender cómo el trastorno de estrés postraumático (TEPT) podría causar cambios duraderos en el cuerpo y la mente. Entender la comorbilidad (cuando hay dos enfermedades presentes) puede ser importante al manejar la atención y proveer el tratamiento. Es posible que este estudio ayude a encontrar los efectos positivos y negativos de algunos tratamientos. También, puede que ayude a los miembros del personal de respuesta y a quienes estén a cargo de su cuidado a determinar qué deben planear para el futuro. El estudio quizás contribuya a que el personal de respuesta adopte comportamientos beneficiosos para la salud a medida que vayan avanzando en edad.

Investigación: Existen muchos indicios que sugieren que lo que hacemos a lo largo de nuestra vida tiene un efecto en cadena y cambia lo que podemos esperar que nos pase en el futuro. Los hombres y las mujeres que respondieron a los eventos del World Trade Center (WTC) tuvieron experiencias que los golpearon física y sicológicamente. Algunos comenzaron a tener TEPT crónico. Se piensa que es posible que el TEPT afecte la salud física. Esta investigación busca examinar si el TEPT podría estar implicado en el daño al cuerpo y a la mente. También busca entender lo que significa ser un miembro del personal de respuesta del WTC que está avanzando en edad.

Población: Trabajamos de cerca con los hombres y las mujeres que respondieron a los eventos del WTC el 11 de septiembre y que se hacen los exámenes de supervisión médica en los centros médicos de la Universidad Stony Brook.

Hallazgos: Los síntomas del TEPT pueden aumentar a lo largo del tiempo en algunos de los miembros del personal de respuesta que están experimentando problemas relacionados con el avance de la edad. Los diagnósticos de afecciones relacionadas con el WTC pueden empeorar los síntomas del TEPT. Es más probable que la memoria en los miembros del personal de respuesta del WTC sea peor que en otras personas de la misma edad y sexo. Encontramos una relación entre el TEPT y la presencia de cambios en la forma en que funcionan las células a nivel del ARN. Los síntomas del TEPT con frecuencia son concomitantes con los síntomas de afecciones respiratorias como la tos y el reflujo estomacal. El TEPT también fue asociado a cambios en la personalidad. Sus síntomas han tenido un impacto bastante desolador en el funcionamiento familiar de algunos de los miembros del personal de respuesta. Estas personas con TEPT parecen caminar más lento y tener una mayor dificultad para levantarse de una silla, lo cual podría continuar empeorando con la edad.

Fizyczne i psychiczne choroby współistniejące z PTSD u Ratowników WTC

Potencjalny wpływ: Niniejsze opracowanie przybliża nas do zrozumienia, jak przewlekły zespół stresu pourazowego (PTSD) może powodować trwałe zmiany w ciele i umyśle. Zrozumienie chorób współistniejących (gdy występują dwie choroby) może mieć duże znaczenie dla zarządzania opieką i terapią. Badanie może pomóc odkryć pozytywne i negatywne skutki uboczne niektórych terapii, a także pomóc ratownikom i ich opiekunom ustalić, co należy planować na przyszłość. Nasze badanie może pomóc ratownikom angażować się w zachowania korzystne dla zdrowia, wraz z postępowaniem wieku.

Badanie: Istnieje wiele dowodów na to, że to, co robimy w życiu, wpływa na to, czego możemy spodziewać się na późniejszych jego etapach. Mężczyźni i kobiety, którzy pełnili rolę ratowników po zamachu na World Trade Center (WTC), zostali fizycznie i psychicznie okaleczeni przez te przeżycia. U niektórych rozwinął się przewlekły zespół PTSD. Uważamy, że PTSD może mieć wpływ na zdrowie fizyczne. To badanie ma na celu określenie, czy PTSD może szkodzić na ciało i umysł. Staramy się również zrozumieć, co oznacza bycie ratownikiem WTC po latach.

Populacja: Ściśle współpracujemy z mężczyznami i kobietami, którzy byli ratownikami WTC po zamachu 9/11 i uczestniczyli w badaniach w klinikach Stony Brook University.

Ustalenia: Objawy zespołu stresu pourazowego mogą narastać z upływem czasu u niektórych pacjentów, u których występują problemy związane ze starzeniem. Diagnoza choroby związanej z WTC może pogorszyć objawy PTSD. Ratownicy WTC są bardziej narażeni na pogorszenie pamięci niż inne osoby tego samego wieku i płci. Powiązaliśmy przewlekły zespół PTSD ze zmianami w funkcjonowaniu komórek na poziomie RNA. Objawy PTSD często współistnieją z objawami chorób układu oddechowego, takimi jak kaszel i refluks kwasowy. PTSD powiązano również ze zmianami osobowości. Objawy PTSD miały druzgocący wpływ na funkcjonowanie rodzin niektórych ratowników. Niektórzy ratownicy cierpiący na PTSD mają wolniejszy chód i trudności przy wstawaniu z krzesła, które mogą nasilić się w starszym wieku.

WTC 救助人員中 PTSD 的身心合併症

潛在影響: 本研究讓我們更加瞭解慢性創傷後壓力症 (PTSD) 如何造成身體和精神的持久變化。瞭解合併症(同時患有兩種疾病時)在管理護理和提供治療方面可能較為重要。本研究可能有助於發現一些治療方法的負面和積極的副作用,也可能有助於救助人員和其照顧者決定未來計劃。我們的研究可能有助於讓救助人員隨著年齡增長參與有益健康的行為。

研究: 有很多證據表明,我們在生活中做的事會產生連鎖反應,改變以後生活中可能發生的事情。遭遇世界貿易中心 (WTC) 事件的男性和女性因其經歷而在生理和心理上遭受重大打 擊。一些人已經發展成慢性 PTSD。我們認為 PTSD 可能會影響身體健康。本研究試圖檢查 PTSD 是否會對身心 造成一些傷害。我們也試圖瞭解 WTC 救助人員日漸年邁代表什麼意義。

人群: 我們與遭遇 9/11 WTC 事件的男女密切合作,並在石溪大學診所進行檢測。

研究結果: 在一些經歷老齡化問題的救助人員中,PTSD 的症狀會隨著時間推移而惡化。WTC 相關病症的診斷會使得 PTSD 症狀惡化。WTC 救助人員的記憶力比同齡且同性別的其他人更差。我們將慢性 PTSD 的變化與核糖核酸 (RNA) 層面的細胞功能變化關聯起來。PTSD 的症狀通常伴有咳嗽和酸反流等呼吸疾病症狀。PTSD 也與個性的變化有關。PTSD 症狀對於一些救助人員的家庭功能具有相當大的毀滅性影響。一些患有 PTSD 的 救助人員似乎走路較慢,從椅子上起來更困難,隨著年齡的增長,這種情況可能會繼續惡化。


Psychological Resilience and Posttraumatic Stress in WTC Rescue and Recovery Workers
Adriana Feder, MD
Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai

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Dr. Feder: Thank you, Evelyn. So thank you to NIOSH for having me here, and for organizing this event. So I am a clinician. I started out as a clinician and then I also became a researcher, but at Mount Sinai, I have been treating rescue and recovery workers who worked at Ground Zero and the landfill, etc., so WTC responders, since 2007. So I have a lot of experience talking to responders and helping them, trying to help with the things that the symptoms they're having and the experiences that they’ve gone through. And also, my research focus, as Evelyn, Dr. Bromet, mentioned is on resilience, on trauma and risk and resilience.

And so we have a program at Mount Sinai, based at Mount Sinai, myself and in collaboration with other researchers at Mount Sinai and also my colleagues at Yale, Robert Pietrzak and Steve Southwick, that started thanks to the funding from NIOSH a few years ago. And we started out trying to understand, looking at trajectories over time from PTSD symptom questionnaires that were collected at the monitoring program at the various, the five different Clinical Centers of Excellence and periodically, from responders coming for monitoring. And we noticed, like other groups of researchers, that some people had a more resilient or lower-symptom trajectory or had bounced back, and other people had worsening or more chronic trajectories.

And so then what we decided to do was apply for funding to NIOSH to look at what might be potentially protective factors as well. So we fielded a web-based survey to over 4,000—over 4,000 responders completed a survey over the internet. And then we built up on that by obtaining funding to conduct a study of blood biomarkers to bring in a subgroup of over 300-350 responders to do more in-depth interviews and look at blood markers, including genetics, epigenetics that Dr. Clouston was talking about, and then also moving into try to get the whole picture with brain imaging and also intervention, trying to see if we can help improve PTSD symptoms in responders.

So there isn’t enough time to talk about everything that we’re doing in the program but I wanted to mention a couple of things. In our web-based survey and our trajectory studies, we confirmed findings from other groups that those who were having persistent and more severe Post-Traumatic stress symptoms like nightmares, memories, reexperiencing, tended to have more severe exposures. So they were more directly exposed to the attacks. Either they were there when they happened or they worked on the pile directly, or they might have colleagues or family members who were lost in the attacks. And also, subsequent stressful life events like losing a job or losing a family member or separation seemed to build up and make the trauma more difficult to cope with.

And also, having medical problems, as we heard that mental health and physical problems, it’s all one body—the brain is in the body as well—go together. So that also compounds. And then from the web-based survey… Oh, one other thing I wanted to mention is that one thing when we brought the responders, between 350 and 400 responders who came in person, and we also looked at blood biomarkers, we found that childhood trauma, so more stressful childhood environments like abuse or neglect, compounds the experience of World Trade Center exposure together with some forms of genetic predisposition.

For example, a protein, a gene that makes a protein in the blood that helps the stress, the hormones, stress hormones and the stress response in the body. So there seems to be a particular interaction between severity of childhood trauma, World Trade Center exposure and certain gene variants in the body that makes it more difficult for some people because they're at higher risk for PTSD; and then other people who have been lower exposed to trauma and also have the more protective genes are more likely to be resilient. So it’s very complex and it takes a lot of time to study, and our colleagues in Stony Brook are also studying genetics, gene expression, epigenetics. So we will have, in the next few years, I anticipate we are going to have a lot of interesting and informative findings.

In terms of coping strategies, we also asked on the web-based survey, what are the three most common coping strategies that you have been using to cope with 9/11-related problems that you have encountered. And so we found, similarly to other populations who were exposed to severe traumas, that avoiding or not dealing with problems is not as helpful, although if you are very symptomatic, sometimes that’s what happens.

We found that accepting or being able to gradually coming to terms with having illnesses or the losses that came from 9/11 is important, and also trying to find a positive angle. Trying to grow, if at all possible, from the events. For example, you found new friendships with other survivors or responders or perhaps you, if you’ve been able to overcome some of the stress, you can share it with others or start a group or join a group to help others who are still struggling. So trying to positively reframe.

And then we also found that—and similarly, taking action. So instead of passively resigning oneself, to take action to deal with the problem, like getting help, getting medical care, going to monitoring, for example.

And we also found like in other survivors, other studies of trauma survivors, that a social support network is associated with better mental health and also being able to regain a sense of purpose and life. Those who had lower symptom levels over time were more likely to report that they had a better sense of purpose. Now, this particular study we can’t say what's cause and effect. We just know that it goes together. And so some people need to, of course, access mental health treatment and even counselling, medication in order to be able to get to that point.

And finally, I briefly wanted to mention, right now we are fortunate to be funded by NIOSH to conduct a study of online writing therapy. This one is for responders, very broadly defined—police, firefighters, construction workers, Red Cross volunteers, a whole range of responders. And there are flyers outside and the best way to find out about the study is to log in to our webpage because that’s how you enter the first steps of the study to be evaluated. And it’s for responders who are still having significant PTSD symptoms.

From our survey, we found of the 4,000 who completed the survey, we found that about a third of responders out there are still suffering from clinically significant PTSD symptoms. Perhaps not everyone full PTSD, but symptoms that are associated with impairment in their functioning at work or relationships, like distancing themselves from others or still having sleep problems, still being really disturbed by memories or when they are exposed to reminders of 9/11 and their work for the World Trade Center recovery.

And so what we do is we pair them up—we first do an assessment online and over the phone. And I see that the light is red so I’ll take half a minute. Five seconds. So we assign them with a therapist and they have writing exercises twice a week for eleven writing exercises over six weeks.

And we are comparing two forms of therapy, one that focuses, incorporates their experience of 9/11 and coping, and the other one focuses on current stressors and problem-solving.

So anyways, there's a whole program of study that hopefully we’ll have some more findings for you in the next few years. Thank you.

Study Fact Sheet
Coping with PTSD in the World Trade Center (WTC) Health Program

Potential Impact: Potential Impact: This study is important for WTC survivors and the field of therapy at large. It provides a unique, Spanish-translated, cost-effective, mind-body therapy that helps many mental health and physical health issues.

Research: People exposed to 9/11 can have a range of PTSD symptoms. These may include: upsetting memories, nightmares, feeling detached from others, fears of another attack, or having trouble sleeping. We are interested in ways to cope that might lessen PTSD symptoms. Our current new research looks at writing therapy for WTC responders, assisted by a therapist online, to see if it can help cope with PTSD symptoms.

Population: The first study used an Internet-based survey an average of 12 years after 9/11. Over 4,000 WTC rescue and recovery workers who had done at least three health monitoring visits at the WTC Health Program took the survey. The current study compares two online writing therapies for WTC rescue and recovery workers who continue to have PTSD symptoms. People in the study work with a personal therapist, who interacts with them in writing through the Internet.

Findings: In the first study, WTC responders who were less distressed (had fewer PTSD symptoms) were more likely to use certain ways of coping with stress and trauma. Some of these ways of coping include coming to terms with the effects of the trauma (for example, coming to terms with having illnesses from WTC exposures), being able to look for something positive even during stressful times (for example, feeling closer to others, helping each other, finding one’s personal strengths), and finding or regaining a sense of purpose in life.

Cómo sobrellevan los efectos emocionales del TEPT los pacientes del Programa de Atención Médica del World Trade Center (WTC)

Impacto potencial: Realizamos un estudio en el que se analizaron las formas de sobrellevar emocionalmente el impacto de los eventos del 9/11 y del trabajo de recuperación en el personal de respuesta del WTC. Saber más sobre las estrategias que más frecuentemente usan los miembros del personal de respuesta del WTC que tienen menos angustia (se sienten mejor) puede ayudar a enfocar el tratamiento de la población del WTC que tiene TEPT y reducir sus síntomas. Es posible que también ayude a orientar el tratamiento futuro para el TEPT en trabajadores de rescate y recuperación.

Investigación: Las personas expuestas a los eventos del 9/11 pueden tener una variedad de síntomas de TEPT. Estos pueden incluir recuerdos angustiantes, pesadillas, sensación de indiferencia hacia los otros, miedo a otro ataque o dificultad para dormir. Estamos interesados en formas de sobrellevar las emociones que podrían reducir los síntomas de TEPT. La nueva investigación en curso estudia si la escritura terapéutica para el personal de respuesta del WTC, con la ayuda de un terapeuta en línea, contribuye a sobrellevar los síntomas del TEPT.

Población: El primer estudio utilizó una encuesta en la Internet por un promedio de 12 años después del 9/11. Más de 4000 trabajadores de rescate y recuperación del WTC, que habían tenido al menos tres visitas de supervisión de la salud en el Programa de Atención Médica del WTC, completaron la encuesta. El estudio actual compara dos opciones de escritura terapéutica en línea para los trabajadores de rescate y recuperación del WTC que continúan teniendo síntomas de TEPT. Las personas que participan en el estudio trabajan con un terapeuta personal, quien interactúa con ellos por escrito a través de la Internet.

Hallazgos: En el primer estudio, los miembros del personal de respuesta del WTC que estaban menos angustiados (tenían menos síntomas de TEPT) tendían más a utilizar ciertas formas de sobrellevar el estrés y el trauma. Algunas de estas formas de hacerlo incluyen la aceptación de los efectos del trauma (por ejemplo, aceptar que tienen enfermedades debido a las exposiciones del WTC), ser capaces de buscar algo positivo aun en los momentos estresantes (por ejemplo, sentirse más cerca de los otros, ayudarse mutuamente, encontrar las propias fortalezas), y descubrir o recuperar un sentido de propósito en la vida.

Radzenie sobie z PTSD w ramach Programu Ochrony Zdrowia World Trade Center (WTC)

Potencjalny wpływ: Przeprowadziliśmy badanie, które ocenia sposoby postępowania ze skutkami ataku 9/11 i powrotu do zdrowia u ratowników WTC. Zdobycie wiedzy na temat strategii postępowania stosowanych najczęściej przez ratowników WTC, którzy są mniej przygnębieni (czują się lepiej) może pomóc skoncentrować się na leczeniu PTSD w populacji WTC i łagodzić objawy PTSD. Może ona również w przyszłości pomóc w leczeniu PTSD u osób pracujących przy akcji ratowniczej WTC.

Badanie: Osoby narażone na ekspozycję 9/11 mogą mieć różne objawy PTSD. Mogą one obejmować: przykre wspomnienia, koszmary, uczucie oddzielenia od innych, obawy przed kolejnym atakiem lub problemy ze snem. Jesteśmy zainteresowani takimi metodami leczenia, które mogą łagodzić objawy PTSD. Bieżące nowe badanie dotyczy terapii pisemnej dla ratowników WTC, prowadzonej przez terapeutę w trybie online. Celem jest sprawdzenie, czy taka terapia pomaga poradzić sobie z objawami PTSD.

Populacja: Pierwsze badanie zostało oparte na ankiecie internetowej przeprowadzonej średnio 12 lat po 9/11. Ankietę wypełniło ponad 4 tys. osób pracujących przy akcji ratowniczej WTC, które przeszły co najmniej trzy wizyty kontrolne w ramach Programu Ochrony Zdrowia WTC. Obecne badanie porównuje dwie internetowe terapie pisemne dla osób pracujących przy akcji ratowniczej WTC, które nadal odczuwają objawy PTSD. Osoby biorące udział w badaniu współpracują z osobistym terapeutą, który porozumiewa się z nimi pisemnie za pośrednictwem Internetu.

Ustalenia: W pierwszym badaniu, ratownicy WTC, którzy byli mniej przygnębieni (odczuwali mniej objawów PTSD), częściej stosowali określone sposoby radzenia sobie ze stresem i traumą. Niektóre ze sposobów radzenia sobie z tym problemem obejmują pogodzenie się ze skutkami traumy (na przykład pogodzenie się z chorobą wywołaną przez ekspozycję WTC), umiejętność znalezienia pozytywnych aspektów nawet w stresujących momentach (na przykład bycie bliżej innych, pomaganie sobie nawzajem, znajdowanie swoich osobistych mocnych stron) oraz znajdowanie lub odzyskiwanie poczucia celu w życiu.

應對世界貿易中心 (WTC) 健康計劃中的 PTSD

潛在影響: 我們完成了一項研究,探討如何應對 9/11 事件的影響及 WTC 救助人員的復原工作。進一步瞭解哪些應對策略常被沒那麼痛苦(感覺更好)的 WTC 救助人員使用,從而幫助集中治療 WTC 人群中的 PTSD 並減輕 PTSD 症狀。 這也可能有助於指導救援和復原工作者的 PTSD 的未來治療。

研究: 暴露於 9/11 事件的人士可能發生一系列的 PTSD 症狀。其中可能包括:痛苦的記憶、噩夢、遠離他人的感覺、擔心另一次攻擊,或者無法入眠。我們對可能減輕 PTSD 症狀的應對方法感興趣。我們目前的新研究 著眼於 WTC 救助人員的寫作治療,在線上治療師的協助下,看看是否可 以協助因應 PTSD 症狀。

人群: 第一項研究在 9/11 事件之後進行了平均 12 年的網際網路型調查。超過 4,000 名在 WTC 健康計劃中進行了至少三次健康監測訪視的 WTC 救援和復原工作者參加了這項調查。 目前的研究針對適用於仍然存在 PTSD 症狀的 WTS 救援和復原 工作者的兩項線上寫作治療進行比較。研究對象與一位私人治療師合作,治療師透過網際網路以書面形式與他們交流。

研究結果: 在第一項研究中,不太痛苦的(具有較少 PTSD 症狀的) WTC 救助人員使用某些方式來因應壓力和創傷的可能性更高。 其中一些因應方式包括接受創傷的影響(例如,適應 WTC 暴露導致的疾病),即使在情緒緊張的時候也能夠尋找到積極的啟示(例如,與他人親近、互相幫助、發現自己的個人優點),找到或重拾人生目標。


Relaxation Response in Spanish-speaking WTC Disaster Survivors with PTSD
Lucia Ferri, PhD
Psychologist, World Trade Center Environmental Health Center, Bellevue Hospital; Clinical Instructor, Department of Psychiatry, NYU School of Medicine

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Dr. Ferri: Hello, I want to say thank you to everyone here for giving me the opportunity to tell you about this study, and to NIOSH for the support in conducting the study.

So I’m Lucia Ferri, I’m Assistant Mental Health Director of the World Trade Center Clinic here at Bellevue Hospital, and I am also a psychologist there so I see patients for mental health treatment in the clinic.

So our World Trade Center Environmental Health Center serves a survivor population, which is basically anyone who was not a first responder that was present on the day or in the months afterwards and had some kind of mental or physical health condition that come to our program for screening and treatment.

And to say a little bit more about our population, a large percentage of our survivors screen positive for mental health symptoms like PTSD, anxiety, depression and a number of other conditions. We find that these symptoms have persisted over the years, and they are also comorbid, as a lot of my colleagues have mentioned, with other medical conditions including respiratory illnesses, gastrointestinal illnesses, cancers and other conditions.

So in our population, about 33% of our survivor population in our program identifies as Hispanic. We've found that the Hispanic patients report higher rates of PTSD, anxiety and depression. that they report that these symptoms persist over the years, and they also have very high rates of respiratory illness and other medical health conditions. Research has shown, and a lot of the research you’ve heard earlier today speaks to, the effects of PTSD, mental health and the relationship with physical health symptoms as well. So what we know is prolonged PTSD really results in a chronic stress response that can affect physical functioning as well, physical health as well.

There is little research on clinical treatments for Spanish-speaking individuals with mental health needs like the ones we see in our population. And due to the presence of both PTSD, anxiety, depression and other mental health symptoms along with the medical symptoms, we really strive to find treatments that can address both the mental health and the physical symptoms that our patients are dealing with over the years.

So in this study, we sought to assess the feasibility and acceptability of this mind-body treatment that has been used at Stony Brook with responder population to good effect, to really treat our Spanish-speaking World Trade Center survivors with chronic and persistent PTSD symptoms. It’s the Relaxation Response Resiliency or 3RP treatment program. It’s a mind-body focused group psychotherapy treatment that has been shown to good effect at Stony Brook. It teaches patients to elicit the body’s natural relaxation response. This relaxation response is proven to have positive effects on many mental and physical health problems including PTSD and respiratory symptoms in the research.

So we first translated the manual into Spanish, along with all the worksheets, and adapted it for use with our Spanish-speaking population. We then recruited 20 Spanish-speaking World Trade Center survivors with persistent PTSD symptoms who were interested in participating in the group psychotherapy. Participants were divided into four groups of four to six members each, and they met for eight weekly sessions of group psychotherapy that lasted an hour and a half each. Groups were led by a Spanish-speaking PhD-level psychologist.

At the first group psychotherapy, participants were provided with binders that included the patient manual, worksheets and weekly homework assignments that they utilized at each group session to read along with the group content and complete in-session worksheets and exercises, and then they had exercises that they had to do during the week at home and then report back.

Participants completed measures of PTSD, anxiety, depression, medical symptoms, life functioning, health promoting behaviors and mindfulness at three time points. It was a lot of questions. They first answered these questionnaires at baseline, which was before they started the groups, then at—oh, am I done already? No, okay. Sorry, then—

Dr. Bromet: No, you have three minutes and twelve seconds.

Dr. Ferri: Okay, then at exit, upon completing the group psychotherapy sessions, and at one-month follow-up. So let me tell you about the group quickly.

We had a diverse group of participants from the Dominican Republic, Puerto Rico, Guatemala, Ecuador, Colombia, Mexico, Honduras, Bolivia. It’s representative of our population; they come from all over. They all identified as Hispanic. The average age of our group members was 55 years old, and we did have 50% male and 50% female. They were exposed to the disaster as local workers, cleanup workers and residents. Seventy-five percent, or 15 of our participants, completed all the group psychotherapy.

And what we found is a decrease in symptoms of PTSD, medical symptoms, anxiety symptoms, perceived stress and depression between baseline and exit. Although this was not statistically significant, we did see a decrease in the scores. We also saw an increase in life satisfaction, which was observed between baseline and exit, and as well as one-month follow-up. What we did find statistically significant was the change in a measure of general health promoting behaviors. Participants reported an increase in physical activity and a significant improvement in stress management through the course of the group and by the end.

In open-ended interviews, they were asked about changes in their symptoms and health, perceptions of the group and overall experience, and all the participants reported that they benefited from this treatment program and they really liked it. They, all of them mentioned they really like learning the different breathing relaxation exercises. They also reported making positive changes to their diet and exercise routines as they learned in this program. They didn’t love the homework, but I don’t know who does. Many people did it and many didn’t.

Okay. So okay, so overall, this study provides preliminary evidence for supporting the clinical effects of this group psychotherapy treatment. And before I end, I want to tell you a little bit about what we did in the treatment and how we—and what we thought it taught and was effective.

So it’s really a treatment about resilience, a word that you’ve heard here from other speakers. And it’s characterized by several factors that are actually themes and topics that we discussed in the group psychotherapy sessions. So group members learned about, one, awareness of the stress response, which is like a flight, fight or freeze response in the body and how it affects the body and its functioning.

They also learned about the ability to bring about the relaxation response through a number of breathing relaxation exercises, other meditative techniques. We even did yoga, chair yoga. The ability to recognize negative thoughts. The ability to create adaptive thoughts and positive expectations. Also, developing a more optimistic and positive perspective by appreciating positive experiences on a daily basis that we actually reviewed in the groups. Increasing a sense of connectedness through social support, empathy and prosocial behaviors like acts of helping others or volunteering or sharing. And also, changing to healthful sleep, eating and exercise habits.

So overall, this treatment protocol had a positive effect on the participants. It was really well-liked. As it has shown efficacy, I look forward to continuing to use this protocol as one of our treatments offered, and to really further investigate the benefits of this treatment in larger populations over time. Okay, did it, thanks.

Study Fact Sheet
A Pilot Test of the Relaxation Response Resiliency Program (3RP) in Spanish-speaking World Trade Center (WTC) Survivors with Post Traumatic Stress Disorder (PTSD)

Potential Impact: This study is important for WTC survivors and the field of therapy at large. It provides a unique, Spanish-translated, cost-effective, mind-body therapy that helps many mental health and physical health issues.

Research: There is little research on clinical treatments for Spanish-speaking people with mental health needs like those in the WTC Health Program. This research looks how well the Spanish-speaking survivor population accepted the 3RP treatment. 3RP treatment is a type of mind-body focused group psychotherapy. Researchers at Stony Brook University have proven that 3RP is as an effective treatment for WTC responders.

Population: The WTC Environmental Health Center (EHC) serves survivors of 9/11 with mental and physical health problems as a result of their exposures to the WTC disaster. Over a third of survivors in the WTC EHC identify as Hispanic. In studies looking at rates of WTC-related PTSD, Hispanics are more likely to report PTSD symptoms. At the initial visit, Hispanics in the WTC EHC survivor program are also more likely to report higher rates of mental health symptoms than other ethnic groups in the survivor population.

Findings: The 3RP treatment teaches people how to bring about the body’s natural relaxation response. This relaxation response has proven to have positive effects on many mental and physical health problems, including PTSD as well as breathing problems. This treatment improved mental health symptoms and helped people in the study make positive changes to their general health behaviors.

Prueba piloto del Programa de Resiliencia y de Respuesta de Relajación (3RP) en sobrevivientes hispanohablantes del World Trade Center (WTC) con trastorno de estrés postraumático (TEPT)

Impacto potencial: Este estudio es importante para los sobrevivientes del WTC y el campo de las terapias en general. Ofrece una terapia única para el cuerpo y la mente, traducida al español y eficaz en función de los costos, que brinda ayuda para muchos problemas relacionados con la salud física y mental.

Investigación: Hay pocas investigaciones dedicadas a los tratamientos clínicos para personas hispanohablantes con necesidades de salud mental, como es el caso de aquellas que participan en el Programa de Atención Médica del WTC. Esta investigación observa cómo fue aceptado el tratamiento del 3RP en la población de sobrevivientes hispanohablantes del WTC. El tratamiento del 3RP es un tipo de sicoterapia grupal enfocada en la conexión del cuerpo y la mente. Los investigadores de la Universidad Stony Brook han comprobado que el 3RP es un tratamiento eficaz para el personal de respuesta del WTC.

Población: El Centro de Salud Ambiental del WTC (EHC, por sus siglas en inglés) atiende a los sobrevivientes del 9/11 con problemas de salud físicos y mentales que resultaron de haber estado expuestos al desastre del WTC. Más de un tercio de los sobrevivientes del Centro de Salud Ambiental del WTC se identifica como hispano. En los estudios que analizaron las tasas del TEPT relacionado con el WTC, los hispanos tenían más probabilidades de reportar síntomas de TEPT. En la visita inicial, los hispanos incluidos en el programa de sobrevivientes del Centro de Salud Ambiental del WTC también tenían una mayor probabilidad de reportar tasas más altas de síntomas relacionados con la salud mental, en comparación con otros grupos étnicos de la población de sobrevivientes.

Hallazgos: El tratamiento del 3RP enseña cómo provocar la respuesta de relajación natural del cuerpo. Se ha comprobado que esta respuesta de relajación tiene efectos positivos sobre los problemas de salud físicos y mentales, incluidos el TEPT y los problemas respiratorios. Este tratamiento mejoró los síntomas relacionados con la salud mental y ayudó a las personas que participaron en el estudio a hacer cambios positivos en sus comportamientos generales relacionados con la salud.

Pilotowa próba przeprowadzona w ramach Programu Zdolność zdrowienia w reakcji na Relaks (Relaxation Response Resiliency Program – 3RP) u hiszpańskojęzycznych Osób Ocalałych z World Trade Center (WTC), cierpiących na zespół stresu pourazowego (PTSD)

Potencjalny wpływ: Badanie jest ważne dla osób ocalałych z WTC oraz dla terapii w ogólnym ujęciu. Umożliwia wprowadzenie unikalnej, przetłumaczonej na język hiszpański i niedrogiej, terapii ciała i umysłu, która pomaga rozwiązać wiele problemów zdrowia psychicznego i fizycznego.

Badanie: Istnieje niewiele badań terapii klinicznych osób hiszpańskojęzycznych z takimi zaburzeniami zdrowia psychicznego, jak te objęte Programem Ochrony Zdrowia WTC. Badanie to zajmuje się kwestią, jak populacja hiszpańskojęzycznych osób ocalałych reaguje na terapię 3RP. Terapia 3RP to rodzaj psychoterapii grupowej, koncentrującej się na sferach ciała i umysłu. Naukowcy ze Stony Brook University dowiedli, że terapia 3RP jest skuteczna w leczeniu ratowników WTC.

Populacja: Środowiskowe Centrum Zdrowia WTC (EHC) świadczy usługi osobom ocalałym z 9/11, cierpiącym z powodu problemów zdrowia psychicznego i fizycznego, powstałych w wyniku ekspozycji podczas katastrofy WTC. Ponad jedna trzecia ocalałych, korzystających z EHC identyfikuje się jako osoby hiszpańskojęzyczne. Według badań, osoby hiszpańskojęzyczne częściej zgłaszają objawy zespołu PTSD związane z WTC. Na wizycie początkowej w EHC osoby te również częściej zgłaszają objawy ze strony zdrowia psychicznego niż przedstawiciele innych grup etnicznych w populacji osób ocalałych.

Ustalenia: Terapia 3RP uczy, jak doprowadzić ciało do naturalnej reakcji relaksacyjnej. Reakcja relaksacyjna okazała się mieć pozytywny wpływ na wiele problemów zdrowia psychicznego i fizycznego, włączając PTSD, jak również problemy z oddychaniem. Terapia łagodzi objawy ze strony zdrowia psychicznego i pomaga wprowadzać pozytywne zmiany w zachowaniach dotyczących ogólnego stanu zdrowia.

講西班牙語且罹患創傷後壓力症 (PTSD) 的世界貿易中心 (WTC) 倖存者的放鬆反應復原計劃 (3RP) 的 先導測試

潛在影響: 本研究對 WTC 倖存者和整個治療領域都很重要。它提供了一個獨特、西班牙語翻譯版的具有成本效益的身心治療,有助於解決許多精神健康和身體健康問題。

研究: 對於像 WTC 健康計劃中那些有心理健康需求的講西班牙語的人而言,臨床治療的研究很少。 本研究探究講西班牙語的倖存者接受 3RP 治療的效果如何。 3RP 治療是一種以身心為中心的集體心理治療。石溪大學的研究人員已經證明 3RP 對於 WTC 救助人員是一種有效的治療方法。

人群: WTC 環境健康中心 (EHC) 為 9/11 事件中因 WTC 爆炸案而導致身心健康問題的倖存者提供服務。WTC EHC 中超過三分之一的倖存者確定為西班牙裔。在調查 WTC 相關 PTSD 發病率的研究中,西班牙裔人士更有可能報告 PTSD 症狀。在最初的訪視中,WTC EHC 倖存者計劃中的西班牙裔人士比倖存者中其他族裔報告心理健康症狀的幾率更高。

研究結果: 3RP 治療教導人們如何帶來身體的自然放鬆反應。這種放鬆反應經證實對許多精神和身體健康問題(包括 PTSD 以及呼吸問題)有正面 影響。這種治療改善了精神健康症狀,並幫助研究對象對其一般健康行為進行積極改變。


Considering New WTC-Related Conditions
Steven Markowitz, MD
Professor and Director, Barry Commoner Center for Health and the Environment, City University of New York

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Dr. Markowitz: Hi, good morning, thanks. So I’m supposed to talk about how to think about adding additional conditions to the WTC covered list, which is really addressing causation, causation of disease. And disease causation is hard. It’s hard for you to understand and it’s hard for us to understand, so let me just start with that.

In fact, if you think about some new condition—forget WTC for the moment but if you think about some new health problem that you developed and you went to your physician for attention to that, and it could be pneumonia, it could be a fungal infection of your nail, it could be lupus or what have you—and you recall your visit to the doctor, my question is did causation actually ever come up? Was there any discussion with the doctor about why did I get this, why me? Why did I get this disease? What was the cause of this disease?

And my guess is it didn’t come up because what you spent your time talking about was diagnosis, what's the problem here, what's the nature of the problem, and also what the treatment is. What can we do about that problem? And that’s right because that’s actually our priority is diagnosis and treatment. And my guess, further, is that actually you didn’t even realize the issue of what caused this with the doctor because you knew that the doctor didn’t know, or you knew it wouldn’t be a fruitful discussion. And in fact, my guess also is in the World Trade Center, if you discuss those issues with your non-World Trade Center physician, the answer is equally absent of any information. And that’s because disease causation is hard because we spend most of our time talking about diagnosis and treatment.

In fact, if you think about the past medical history, you think about that form you fill out when you got to the doctor or what the doctor reviews in terms of symptoms, there is no equivalent exposure history. They don’t talk about what you were exposed to, World Trade Center or otherwise. They don’t go talk about your neighborhood, your home, what job you had or the like. And the price we pay for that is ignorance, is that we simply don’t know a lot about toxins and what they do.

Now, I think it’s useful to—switching now—I think it’s useful to talk about how NIOSH looked at cancer, because NIOSH went through the review process with cancer and decided that cancer would be a covered condition. So let’s just take a moment and review what considerations they looked at.

First of all, they looked at the epi studies that Dr. Webber talked about this morning and others, Dr. Lucchini, the epidemiology studies, and they looked at the results. And in fact, the results were, I would say, preliminary because not that much time has passed, and there was a modest signal of excess cancer. Some cancers, maybe it was exposure-related, maybe not, but there was a modest signal. So that’s what the health studies of the workforce and survivors have shown us to date.

Secondly, NIOSH looked at cancers we would expect to occur as a result of known conditions. So we had inflammation of the esophagus as a WTC condition. We know that that can cause esophageal cancer. So we’re going to cover esophageal cancer because it’s related to inflammation; it’s a secondary condition. And that makes a lot of sense.

And then they leaned on—and this is very important—the presence of known carcinogens at the World Trade Center site. So we know asbestos was there, and Dr. Lucchini mentioned this. We knew PCDs were there, dioxin and the like. Now, we knew that because there are decades of research on carcinogens which allow us to say that. You can go to NTP, National Toxicology Program, online. You can go to their report on carcinogens, and you can see their review of hundreds of carcinogens and what we know about them and whether they cause human cancer or not. That results from decades of work that’s been achieved by the scientific community.

Try doing that for autoimmune diseases. Try finding the report on autoimmune diseases by any authoritative government or nongovernmental agency and you won’t find it because it doesn’t exist. We don’t have research as it applies to other outcomes besides cancer. And that’s very important because it means we can’t fall back on a body of knowledge that Dr. Howard mentioned, a body of knowledge to help make that decision about whether this condition could be World Trade Center-related or not.

And then finally, NIOSH used what we call plausibility and coherence, meaning did the toxin get to the site, to the target organ of concern, and does it cause biological changes that could cause cancer? And so we saw a lot of inflammatory conditions as a results of World Trade Center dust exposure, and we know that inflammation is a mechanism that can lead to cancer. So knowing those two facts, that WTC dust caused inflammation and that inflammation can lead to cancer, was important supportive evidence that cancer could be related to World Trade Center conditions. So how much more time do I have?

Dr. Bromet: None.

Dr. Markowitz: I have none, I have no time, so let me continue. Oh, I just got two minutes. Mike Crane just gave me two minutes, thank you, thank you.

Okay, so in the workshop we’ll discuss this further. But I’m thinking about heart disease and WTC, looking at kind of these same factors that NIOSH looked at. Do we have epi studies that show increase in heart disease? Well, there’s some evidence from the World Trade Center Health Registry. That’s one thing. Can conditions related to WTC cause heart disease? Well, PTSD does raise the risk of heart disease, so that’s interesting. Were there known heart toxins at the World Trade Center site?

Well, we know air pollution increases the risk of heart disease, though that leaves a lot of questions about how dust related to air pollution. And then finally, is there plausibility? That is to say, could that dust have gotten to the heart or caused inflammation that could lead to heart disease, on a long-term basis, not just in 2002 but in 2016? And that’s a difficult question.

So that’s application of NIOSH’s criteria to a different condition, and you can see it’s difficult. It’s difficult in part because we don’t have a lot of information, and that information will evolve. My final point is, before Dr. Bromet cuts me off, is to emphasize, so the studies of the World Trade Center populations are key. The epidemiology studies, the surveillance work, the sentinel events that Dr. Moline mentioned before—it’s key to us understanding and being able to cover conditions in the future, and we’ll discuss this more at the workshop. Thank you.

Study Fact Sheet
Considering New World Trade Center (WTC)-related Conditions

Potential Impact: Doctors typically focus on identifying what disease a person might have and how it might be treated. Doctors do not usually address the cause of the disease and provide few answers for people who are become ill and wonder why. Research studies can provide useful information about human diseases. Results of diverse research studies, when viewed together, can provide insights into causes of human diseases.

Research: NIOSH used four methods to examine whether WTC exposures cause cancer. NIOSH reviewed studies of WTC-exposed populations; cancers that are known to occur as a result of the WTC covered conditions; known human carcinogens present at the disaster sites; and other factors recommended by the NIOSH Scientific and Technical Advisory Board.

Findings: Completing studies of large numbers of WTC-exposed people compared to people who did not have WTC exposures is key to determining what additional health conditions may be related to WTC exposures. A problem with this approach is that these studies cannot provide clear answers until sufficient numbers of people develop the health problem of concern. A timely disease surveillance system for WTC-exposed populations will improve this research.

Consideración de nuevas afecciones relacionadas con el World Trade Center (WTC)

Impacto potencial: Los médicos normalmente se concentran en identificar qué enfermedad podría tener una persona y cómo podría tratarse. No suelen abordar la causa de la enfermedad y ofrecen pocas respuestas a las personas que se enferman y se preguntan el por qué. Los estudios de investigación pueden suministrar información útil sobre las enfermedades en los seres humanos. Los resultados de estudios de investigación diversos, al verse juntos, pueden ayudar a comprender las causas de estas enfermedades.

Investigación: NIOSH usó cuatro métodos para examinar si las exposiciones del WTC causan cáncer. Analizó estudios de poblaciones expuestas en el WTC; cánceres que se sabe que ocurren como resultado de las afecciones relacionadas con el WTC que están cubiertas; carcinógenos humanos conocidos, presentes en los sitios de desastre; y otros factores recomendados por la Junta de Asesoramiento Científico y Técnico de NIOSH.

Hallazgos: Para determinar qué otras afecciones podrían estar relacionadas con las exposiciones del WTC, es fundamental que se realicen estudios de comparación entre grandes cantidades de personas que estuvieron expuestas en el WTC y personas que no lo estuvieron. Uno de los problemas que tiene este enfoque es que estos estudios no pueden suministrar respuestas claras hasta que una cantidad suficiente de personas presente el problema de salud concerniente. Un sistema oportuno de vigilancia de enfermedades en las poblaciones expuestas en el WTC mejorará esta investigación.

Nowe choroby powiązane z atakiem na World Trade Center (WTC)

Potencjalny wpływ: Lekarze zwykle koncentrują się na określeniu, na jaką chorobę może cierpieć pacjent oraz jak można ją leczyć. Lekarze zazwyczaj nie wskazują przyczyny choroby i nie udzielają wystarczających odpowiedzi pacjentom, którzy zachorowali i którzy zastanawiają się nad przyczyną swojej choroby. Badania naukowe mogą dostarczać przydatnych informacji o chorobach ludzi. Wyniki różnych badań, rozpatrywane wspólnie, mogą dać wgląd w przyczyny chorób ludzi.

Badanie: Agencja NIOSH zastosowała cztery metody w celu zbadania, czy ekspozycja WTC powoduje raka. Agencja NIOSH zapoznała się z badaniami obejmującymi: populacje narażone na ekspozycję podczas ataku na WTC, nowotwory występujące w wyniku chorób objętych programem WTC, znane ludzkie czynniki rakotwórcze obecne w miejscu katastrofy oraz inne czynniki, zalecane przez Naukowo-Techniczną Radę Doradczą NIOSH.

Ustalenia: Przeprowadzenie badania na dużej liczbie osób poddanych ekspozycji podczas ataku na WTC w porównaniu do osób, które nie były poddane ekspozycji, stanowi klucz do ustalenia, jakie dodatkowe jednostki chorobowe mogą być powiązane z ekspozycją podczas ataku na WTC. Trudność związana z takim podejściem polega na tym, że badania nie dostarczają jasnych odpowiedzi, jeśli dany problem zdrowotny nie rozwinął się u wystarczającej liczby osób. System regularnego nadzoru choroby u populacji narażonej na ekspozycję WTC przyczyni się do poprawy tego badania.

考慮新的世界貿易中心 (WTC) 相關病症

潛在影響: 醫生通常專注於確定所患的疾病,以及如何治療。醫生通常不會解決病因,並且對患者和好奇人士的提問回覆很少。研究可以提供有關人類疾病的實用資訊。結合多種研究結果一起查看時,可以洞察人類疾病的原因。

研究: (美國)國家職業安全與衛生研究院 (NIOSH) 使用四種方 法來檢查 WTC 暴露是否會導致癌症。NIOSH 審查了 WTC 暴露人群的研究;已知因 WTC 涵蓋的病症而發生的癌症;已知在爆炸案現場出現的人類致癌物;以及 NIOSH 科學技術諮詢委員會提及的其他因素。

研究結果: 與沒有 WTC 暴露的人相較之下,完成對大量 WTC 暴露人群的研究是確定哪些額外的健康狀況可能與 WTC 暴露有關的關鍵。這種方 法的問題是,這些研究不能提供明確的答案,直到有足夠多的人罹患受關注的健康問題。WTC 暴露人群的及時疾病監測系統將改進這項研究。


Seeking Evidence for Additional Conditions
David Prezant, MD
Chief Medical Officer, Office of Medical Affairs, Fire Department of the City of New York; Professor of Medicine, Albert Einstein College of Medicine

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Dr. Prezant: Well, thank you for that lovely introduction and thank you for all that came here today. I’m certain it wasn’t for the free food.

I’m certain it was because you care, and you care because this has impacted you, it’s impacted friends and family and coworkers, and that’s either because of direct exposures or because, as administrators, physicians, psychologists, researchers, it/’s impacted you in ways that many of us couldn’t even begin to describe.

And when we’re doing this, we have a unique challenge, and that unique challenge is to remember that we have two functions. The first function is obvious and that is to take care of the individual patient. That person who comes to us is looking for advice, is looking for treatment, and in many ways is looking for closure.

And I remember distinctly being at the bedside of a person who was dying from cancer, a firefighter, and his family was around him and he passed on. And he had many young children, and it was a very emotional event, as you could imagine. And the priest came in and said a few words. It helped a little. And then someone, I can’t remember who, said, “You know, your dad was a hero because he died of cancer because he was there helping people on 9/11.” There was no scientific evidence at the time that cancer was related to 9/11. There was no multimillion-dollar program paying for his cancer treatment. There was no World Trade Center logo over his bedside. But that family, for a moment—and I hope a moment that lasts forever but I know for that moment—that family had closure. That family didn’t need scientific evidence. They didn’t want scientific evidence. For them, Dad was a hero.

That was something that we gave to that family, and by now, covering cancer, that is something we can offer to every family—family of survivors, family of responders, family of patients that succumb to their disease, family of patients that don’t succumb to their disease. It’s more than about research and money; it’s about taking care of human beings and their quality of life. That is our challenge. At the same time, we have another challenge and that is a fiduciary responsibility to the federal government to say there is some science behind this. We hope that there's compassion. We hope, as Dr. Howard did for cancer, that there is compassion, that modest evidence can move us forward, because to not move forward is to miss an opportunity to provide the solace that I just mentioned, something that is invaluable. So we hope that there is comparison but there still needs to be some science because we have a fiduciary responsibility, because we need to have what I often call data-driven advocacy, right. Advocacy without data ultimately winds up being a program without credibility and a program that can’t grow.

And one of the beautiful things about our program is that it has been based on data-driven advocacy. The clinical centers, the data centers, the researchers have provided clear evidence, for respiratory and mental health problems related to 9/11 and increasingly clear evidence for the same related to cancer. A modest increase in cancer only eight years after 9/11 is significant, and we are finding that our future studies are going to demonstrate, I think, that that level of data-driven advocacy and the confidence that the federal government had in our data is well-founded.

And it raises the question about what about something else. What about other issues? And we've been spending a lot of time on that, obviously. What we need is your compassion towards us as researchers, because it takes a lot of time. And I’m supposed to be talking about what it takes to do that today, and we’ll learn more in the workshop, but we ask a lot of questions at the annual monitoring exam, and we ask them over and over again, and then we ask more, and people can get frustrated with that. But we’re not looking for just one disease.

Let us postulate or think for a moment what it would have been if we did what would be a quick annual monitoring questionnaire on 9/11. The obvious thing to those of us who did care—thank you, Dr. Bromet—was mental health/PTSD and respiratory. And clearly as a lung specialist, respiratory is foremost. If that questionnaire was designed with just that in mind, we would have 150 lung questions and maybe 2 or 3 mental health questions, and that would be it. But we had a broader purpose. We wanted to ask questions about cancer. We wanted to ask questions about autoimmune diseases. We wanted to ask questions about potential toxic diseases like liver diseases, kidney diseases, etc. and therefore the questionnaire kept growing.

And when you come to answer that questionnaire that is our beginning basis for picking up data. And then we do tumor matching and then we do treatment exams, and all of that data has to come together, and it has to come together in a way that is somewhat convincing so that we can move forward. And we are working very hard on that, but to get that data requires comparison studies. It requires that we look at control groups. The tumor registries provide us with the control groups for cancer studies. Looking at other workers with less exposure or no exposure provides us with control groups for many of the diseases, but these are control groups that are difficult to come by. There are always differences between controls and our own groups that make some degree of uncertainty, and that’s why we need multiple studies.

And that’s why the federal government has said, when we've presented what I believe to be overwhelming evidence that autoimmune diseases are increased, the federal government said, well, we need to see corroborating studies from the other groups, which actually is one of the strengths of our program. People initially said, well, you don’t need to have a general responder group and an FDNY group and a survivor group, or maybe you just have one group and you just ask the same questions of everybody and that will be perfect because there's more power in numbers. And these are people that don’t really understand. There is more power in numbers but there is also more power in comparisons between different groups that then find the same evidence. That’s what happened with cancer and we’re waiting for that to happen in autoimmune, and I feel very confident that it will, and then we’ll go on to the next and the next and the next.

But we’re now getting an increasing challenge, and that increasing challenge is not just the comorbidity impact of all of these diseases together but there's an increasing challenge of two comorbidities that we all deal with in our own lives that challenge each of us as individuals, and that is, unfortunately, aging and obesity. And many of the studies—I’m sorry, many of the diseases that we are looking at now, many of the questions that are being asked to us by our own patients, loss of memory, inability to exercise, increasing shortness of breath with activity, many of these are some of the same things that we see due to aging and obesity.

So what I want to do is provide you with confidence that we’re looking at this. But what I also want to do at the individual level is empower you. Empower you to make a difference in your own lives, and that is to avoid future toxins, to continue to exercise and lose weight, as hard as that might be, and the biggest challenge—but which I know that at least I am capable of—is to never age.

Study Fact Sheet
Seeking Evidence for Additional Conditions

Potential Impact: Researchers must continue to track and study autoimmune rheumatologic diseases like rheumatoid arthritis or lupus, in an effort to add them to the list of WTC-related conditions. Sarcoidosis is already a WTC-covered condition, but this study helped improve monitoring and treatment of people with sarcoidosis.

Research: This study examined if autoimmune diseases increased after 9/11 exposures. It also aimed to understand if the symptoms appear different in those exposed, compared to those that were not.

Population: Rescue and recovery workers of the Fire Department of the City of New York.

Findings: We found an increase of autoimmune diseases in FDNY rescue/recovery workers who reported greater levels of WTC exposure. We also observed that the symptoms for sarcoidosis are different in those exposed, compared to what we historically expect in the people not exposed to 9/11.

En busca de evidencia de otras afecciones

Impacto potencial: Los investigadores deben continuar el seguimiento y estudio de las enfermedades reumáticas autoinmunitarias, como la artritis reumatoide o el lupus, a fin de agregarlas a la lista de afecciones relacionadas con el WTC. La sarcoidosis ya estaba incluida entre las afecciones cubiertas por el WTC, pero este estudio ayudó a mejorar la supervisión y el tratamiento de las personas que la tienen.

Investigación: Este estudio exploró si aumentó la cantidad de casos de enfermedades autoinmunitarias después de las exposiciones del 9/11. También tuvo como objetivo comprender si los síntomas parecen ser diferentes entre quienes estuvieron expuestos y entre quienes no.

Población: Trabajadores de rescate y recuperación del Departamento de Bomberos de la Ciudad de Nueva York.

Hallazgos: Hallamos un aumento en la cantidad de enfermedades autoinmunitarias en los trabajadores de rescate y recuperación que reportaron mayores niveles de exposición en el WTC. También observamos que los síntomas de la sarcoidosis en aquellos que estuvieron expuestos al 9/11 son diferentes de los esperados históricamente en las personas no expuestas.

Poszukiwanie dowodów na występowanie dodatkowych chorób

Potencjalny wpływ: Naukowcy muszą nadal śledzić i badać autoimmunologiczne choroby reumatologiczne, takie jak reumatoidalne zapalenie stawów lub toczeń, w celu dodania ich do listy chorób powiązanych z WTC. Sarkoidoza jest już objęta programem WTC, ale to badanie pomogło udoskonalić monitorowanie i leczenie osób z sarkoidozą.

Badanie: W tym badaniu oceniano, czy po ekspozycji 9/11 wystąpiła większa zachorowalność na choroby autoimmunologiczne. Jego celem było również wyjaśnienie, czy objawy różnią się w zależności od ekspozycji lub jej braku.

Populacja: Pracownicy nowojorskiej straży pożarnej biorący udział w akcji ratowniczej.

Ustalenia: Zauważono wzrost zapadalności na choroby autoimmunologiczne wśród pracowników FDNY, którzy zgłaszali wyższe poziomy ekspozycji WTC. Zauważono również, że objawy sarkoidozy różnią się u osób narażonych na ekspozycję, w porównaniu do tego, czego można było wcześniej spodziewać się u osób nienarażonych w 9/11.


潛在影響: 研究人員必須繼續跟踪和研究類風濕性關節炎或狼瘡等自身免疫性風濕病,以期將之新增到 WTC 相關病症列表中。肉狀瘤病已屬於 WTC 涵蓋的病症,但本研究有助於改善肉狀瘤病患者的監測和治療。

研究: 本研究檢測了 9/11 暴露後自身免疫性疾病是否增加。本研究也旨在瞭解暴露人群與未暴露人群出現的症狀是否不同。

人群: 紐約市消防局 (FDNY) 的救援和復原工作者。

研究結果: 我們發現 FDNY 救援/復原工作者的自身免疫性疾病增加,他們報告的 WTC 暴露程度較高。我們還觀察到,暴露人群的肉狀瘤病症狀不同於我們既往認為未暴露於 9/11 事件的人群。


What it All Means? Morning Session Wrap-up
Michael Crane, MD, MPH
Medical Director, WTCHP Clinical Center of Excellence at Mount Sinai; Associate Professor, Selikoff Centers for Occupational Health, Mt. Sinai Hospital

To enable sound, click the speaker icon in the lower right of the video after starting the video.

Dr. Crane: So what a fantastic morning. What do you think of our panelists? Weren’t they amazing? Incredible. Absolutely incredible. It’s just fantastic. And I have to say that because Dr. Bromet has a large weight that she’s going to drop on my toe unless I say it, okay. So that’s what she’s doing here. So I’m honored to be here amongst everyone, amongst our responders and survivors, and my fellow providers.

The modest title of my modestly titled talk is “What it all means”. No problem. Seven minutes, I got it. I got it covered. But I think you’ve had hints about what it all means already, right? And the first hint, if you can think back that far, is what Dr. Denise Harrison said. Where is Denise? Where did she…? She’s way in the back. Okay, if you have trouble remembering what she said, just turn around and look at her. It’s okay. It’ll come back, because she was fantastic. She’s so eloquent.

But starting with that, we've had a group of people really tell us a great deal about World Trade. So let’s start talking about what we actually heard. Well, this is a program about a disaster response program, as a categorization, and usually disaster response, you want to talk about the exposure obviously. You want to talk about acute and chronic. You want to talk about the populations, populations exposed. You particularly want to deal with the vulnerable populations to that exposure. You certainly want to talk about diseases, with an emphasis on mental health in disasters. And you want to also cover a myriad of other topics that will kind of fall out of trying to deal with those three.

So today we had wonderful talks about exposure, with Dr. Lucchini talking about the risk of cancer. Leo Trasande, who I think is just a marvel, kind of leading that charge about a really forgotten part of our population, the children, who are extremely vulnerable to this type of exposure, and his beautiful work, painstaking, detailed, beautiful work to show the risks that the kids are having to just one of the chemicals that goes down. So Leo, my hat is always off to you. Just continue the great work, just fabulous. And then our Dr. Webber, who works so hard with the Fire Department, doing a beautiful study. You realize that studies are kind of like baseball pitches, you know. Some are fast balls and some are sliders. Some go right in the dirt. This is a beautiful curve ball that Mayris is throwing, just a beautiful, gorgeous curve ball that’s going to drop in the strike zone about fifteen years from now when the results come through and show that the difference between these two populations of firefighters in terms of outcome is the World Trade Center exposure. It’s beautifully designed; it’s well thought out. Thank you so much, Mayris.

We've had our doctors talking about illness. Dr. Reibman, my colleague Dr. Laura Crowley, Dr. Clouston and Dr. Brackbill really describing the population both in the CCEs and in the Registry, and talking about the illnesses. We've had people who have been doing population—I mean hypothesis-generating studies, like I think Dave Prezant’s study about rheumatoid disease and autoimmune diseases—to generate new thinking about the illnesses that may be coming. And Dr. Reibman of course about the airway disease.

Dr. Markowitz talked about how we think about new conditions, and both Dr. Feder and Dr. Ferri just with us now talked about really exciting new approaches to a terrible illness, PTSD, where people can actually start doing this and hopefully get relief of symptoms. I think this is fantastic work and I’m very, very excited about participating with both of you in the studies.

So we heard a lot of great stuff, right. So is that what it all means? Uhhhh…you kind of stop there and you say maybe, maybe there’s a little something more. So what I think it all means becomes clearer if you turn the title of today’s program on its head. As somebody once said to me, if you really want to see the world, stand on your head. So it comes, Research to Care turns into Care to Research. So David is looking at me—I said that already—and I’m just going to say it again. But it’s not just the care, the medical care.

What it is, I think, what it all means is the inspiration that responders and survivors gave to all of us, their courage, their unselfishness, their willingness to sacrifice themselves and share with the community, and to be the people who still say to me, day after day, oh Doc, I know you got treatments but really, save it for the guy who really needs it. Save it for the person who really needs it, Doc. That doesn’t happen in a lot of places. It’s the unselfishness of you, our populations. And quite frankly, that has inspired us. It has inspired us repeatedly. It has inspired us every single day. It has inspired us this morning. Your care that inspires our research, which then helps our treatment.

So what it all means, it means inspiration. And I’m hoping, I’m hoping that it’s the type of inspiration that can carry us forward even when we have those moments that David and my dear colleague Jackie so eloquently described, of loss, and I hope which will carry us past the site of all these broken hearts. So thanks very much, thanks for this honor. Thanks for being you.

Afternoon Wellness Session Resources

Self Care: Including Yourself in Compassion
Seema Desai, MD
New York University School of Medicine

Study Fact Sheet
Self-Care: Including Yourself in Compassion

Potential Impact/Population: Regular self-care can increase our sense of well-being and prevent burnout among caretakers. Self-care is a crucial part of wellness, especially for people who take care of others in their home and/or work-life.

Tips for Self-Care: Modern research has shown the benefits of ancient wisdom and simple practices that support health and healing. The following is a brief overview of research-based tips for better physical and mental health:

  • Exercise: Move each day. Activities like walking, strength training, or yoga can help ease symptoms and even prevent some physical or mental health issues. Even regular short bursts of gentle movement can help.
  • Healthy Food: Aim for a “rainbow diet.” Add more colorful fruits and vegetables to your plate and include some oily fish like salmon or sardines, which are rich in omega-3 oils and low in mercury. Try to avoid eating too many calories and ask your doctor about supplements like Vitamin D or fish oil.
  • Nature: Being outside in nature is a time-tested way to improve our thought process and overall sense of well-being.
  • Relationships: Good relationships are key to both physical and mental well-being. This ancient idea is now supported by considerable research. Take time to connect with family, friends, neighbors, or pets.
  • Have Fun: Involvement in enjoyable activities, like a favorite hobby or pastime, can be more than just fun. It can bolster our sense of well-being. Even the word recreation shows why it’s important: “re-creation!”
  • Religious/Spiritual Connection: In general, religious or spiritual involvement is most likely to have health benefits when it centers on themes such as love and forgiveness. It can also a good way to connect with supportive relationships.
  • Volunteering and Service: Since ancient times, helping others has been seen as a virtue that can benefit both the giver and receiver. Helping others can reduce unhealthy mental feelings such as greed, jealousy, and being ego-centric. It can also increase healthy feelings like love, joy, and generosity.
  • Relaxation/Stress Management: Mindfulness meditation and mind body practices can be very valuable skills to help improve physical and mental well-being.
Cuidarse a sí mismo: Sea compasivo también con usted mismo

Impacto o población potencial: Cuidarnos a nosotros mismos con regularidad puede mejorar nuestra sensación de bienestar y prevenir el agotamiento cuando nos ocupamos del cuidado de otras personas. Esto es un aspecto crucial del bienestar, especialmente para las personas a cargo del cuidado de otras tanto en el hogar como en el trabajo.

Consejos para cuidarse a sí mismo: La investigación moderna ha comprobado los beneficios de la antigua sabiduría y las prácticas simples que favorecen la salud y la curación. A continuación le brindamos una breve reseña de consejos basados en investigación para mejorar la salud física y mental:

  • Ejercicio: Muévase todos los días. Las actividades como caminar, hacer ejercicios de fortalecimiento muscular o yoga pueden ayudar a aliviar síntomas e incluso prevenir algunos problemas de salud físicos y mentales. Aun hacer una serie corta de movimientos suaves, con regularidad, puede ayudar.
  • Comida sana: Póngase como meta una "alimentación arco iris". Agregue más frutas y verduras coloridas a su plato e incluya algún pescado graso como el salmón o las sardinas, los cuales tienen un rico contenido de ácido graso omega-3 y bajo contenido de mercurio. Trate de no consumir demasiadas calorías y pregúntele a su médico sobre los suplementos como la vitamina D y el aceite de pescado.
  • Naturaleza: Estar al aire libre, rodeado por la naturaleza, es una forma comprobada de mejorar los procesos mentales y la sensación de bienestar general.
  • Vínculos: Tener una buena relación con quienes lo rodean es fundamental tanto para la salud física como para el bienestar mental. Esta idea ancestral ahora está respaldada por muchos trabajos de investigación. Dedique parte de su tiempo a conectarse con sus familiares, amigos, vecinos o mascotas.
  • Diviértase: Hacer actividades que disfrute, como un pasatiempo preferido, puede brindarle más que diversión. Puede renovar su sensación de bienestar. Incluso la palabra "recreación" demuestra por qué es importante: ¡"re-creación"!
  • Conexión religiosa o espiritual: En general, la religiosidado la espiritualidad tienen más probabilidades de beneficiar la salud cuando se centran en temas como el amor y el perdón. También pueden ser una buena manera de conectarnos con personas que nos brinden apoyo.
  • Voluntariado y servicio: Desde la antigüedad, ayudar a los otros ha sido una virtud que puede beneficiar tanto al que da como al que recibe. Ayudar a los otros puede disminuir los sentimientos que no son saludables, como la codicia, los celos y el egocentrismo. También puede aumentar los sentimientos saludables como el amor, la alegría y la generosidad.
  • Relajación y manejo del estrés: La meditación con conciencia plena y las prácticas de mente y cuerpo pueden ser habilidades valiosas para mejorar el bienestar físico y mental.
Dbanie o własne zdrowie: Współczucie dla samego siebie

Potencjalny wpływ/Populacja: Regularne dbanie o własne zdrowie poprawia również samopoczucie pacjenta i zapobiega wypaleniu zawodowemu wśród opiekunów. Dbanie o własne zdrowie stanowi istotny element dobrej kondycji, zwłaszcza dla osób, które opiekują się innymi w domu i/lub w pracy.

Wskazówki dotyczące dbania o własne zdrowie: Współczesne badania wykazały, że znane od dawna zasady i proste ćwiczenia wspomagają proces leczenia i pomagają zachować zdrowie. Oto krótkie omówienie zaleceń opartych na wynikach badań naukowych w zakresie dbania o zdrowie fizyczne i psychiczne:

  • Ćwiczenia: Codziennie zażywaj ruchu. Ruch taki, jak chodzenie, trening siłowy czy joga, może pomóc złagodzić objawy, a nawet zapobiegać powstawaniu niektórych problemów zdrowia fizycznego lub psychicznego. Pomóc mogą nawet regularne krótkie i delikatne ćwiczenia.
  • Zdrowe jedzenie: Postaraj się uzyskać efekt „tęczowej diety”. Jedz więcej kolorowych owoców i warzyw oraz tłustych ryb, takich jak łosoś lub sardynki, które są bogate w tłuszcze omega-3 i zawierają mało rtęci. Staraj się unikać spożywania zbyt wielu kalorii i zapytaj lekarza suplementy takie, jak witamina D lub tran.
  • Natura: Spędzanie czasu na łonie natury to sprawdzony sposób na poprawę procesu myślowego i ogólnego samopoczucia.
  • Relacje z ludźmi: Dobre relacje z innymi ludźmi mają kluczowe znaczenie dla dobrego samopoczucia, zarównow sferze psychicznej, jak i fizycznej. Ta odwieczna prawda ma obecnie poparcie w postaci wyników szeroko zakrojonych badań. Spędzaj czas z rodziną, przyjaciółmi, sąsiadami lub zwierzętami domowymi.
  • Baw się: Przyjemne spędzanie czasu, np. na ulubionym hobby lub rozrywce, może być więcej niż tylko zabawą. Może poprawiać samopoczucie. Nawet słowo „rekreacja” mówi samo, dlaczego jest ona ważna: „re-kreacja” czyli „odtworzenie”!
  • Religia/duchowość: Ogólnie rzecz biorąc, zaangażowanie religijne lub duchowe może prawdopodobnie dobrze wpływać na stan zdrowia, gdy koncentruje się na tematach takich, jak miłość i przebaczenie. Może także stanowić dobry sposób na nawiązanie wspierających relacji.
  • Wolontariat i służenie pomocą: Od czasów starożytnych pomaganie innym było postrzegane jako cnota, która zapewnia korzyści zarówno osobie dającej, jak i otrzymującej. Pomaganie innym może zredukować niezdrowe odczucia, takie jak chciwość, zazdrość i egocentryzm. Może również wzmacniać zdrowe odczucia, takie jak miłość, radość i hojność.
  • Relaks/Zarządzanie stresem: Praktyki medytacyjne i psychosomatyczne to bardzo cenne umiejętności, które mogą poprawić samopoczucie fizyczne i psychiczne.



  • 鍛鍊:每天運動。像步行、力量訓練或瑜伽等活動可以幫助緩解症狀,甚至預防一些身體或心理健康問題。即使是定期短暫的溫和運動也有所助益。
  • 有益健康的食物:以「彩虹飲食」為目標。 飲食中添加更多的五顏六色的水果和蔬菜,並包含鮭魚或沙丁魚等油性魚類,因為這些魚肉富含歐米茄-3 油且含汞量低。盡量避免攝入過多卡路里,並就維生素 D 或魚油等補充劑諮詢您的醫生。
  • 接觸大自然:戶外活動可改善我們的思維過程和整體幸福感,這是一個久經考驗的方法。
  • 人際關係:良好的人際關係是身心健康的關鍵。這個古老的理念現在得到了大量研究的支持。花時間與家人、朋友、鄰居或寵物交流/玩耍。
  • 愉快玩耍:參加愉快的活動,如最喜歡的愛好或消遣,其帶來的不僅僅是樂趣。還可以增强我們的幸福感。甚至娛樂這個詞也能說明為什麼它很重要:「重新創造!」
  • 宗教/精神連結:一般而言,當宗教或精神信仰以愛和寬恕等主題為中心時,最有可能帶來健康益處。這也是一個連接支持性關係的良好方法。
  • 志願活動和服務:自古以來,助人樂就被視為一種使給予者和接受者均能受益的美德。 助人樂可以減少不健康的心理感受,如貪婪、嫉妒和以自我為中心。它還可以增加愛、喜悅和慷慨等健康情緒。
  • 放鬆/壓力管理:沉思冥想和身心練習是有助於改善身心健康之非常有價值的技能。

Sleep in the Context of Wellness and Resilience
Indu Ayappa, PhD and Jag Sunderram, MD
Icahn School of Medicine at Mount Sinai and Rutgers Robert Wood Johnson Medical School

Study Fact Sheet
Sleep in the Context of Wellness and Resilience

Potential Impact: Getting enough good quality sleep is essential to your health and wellness. A good night’s rest can also help build your resilience. Resilience is a type of inner strength that helps you bounce back and push through a hard or stressful situation. To improve overall sleep, it is important to address poor sleep behaviors that make sleep worse and treat problems such as sleep apnea (when breathing stops and starts multiple times during your sleep), chronic rhinosinusitis (nasal infammation that may make breathing through your nose difcult) and posttraumatic stress disorder (PTSD).

Research: We have seen that many WTC responders have poor sleep quality. They experience insomnia and have trouble falling and staying asleep. Chronic rhinosinusitis, obstructive sleep apnea, and PTSD can also contribute to poor sleep quality.

Population: This study looked at Responders, clean-up workers, and other workers who were in lower Manhattan in the weeks and months following 9/11.

Findings: The amount and quality of sleep you get afects how well you function throughout the day, your mood, and your overall quality of life. Poor sleep quality, due to insomnia, sleep apnea, or other health conditions, can weaken your wellness and resilience, increase symptoms of anxiety and depression, and contribute to long-term physical and mental health problems.

Tips to improve your sleep:

  • Turn of your devices an hour before bed;
  • Only drink decafeinated beverages late in the evenings;
  • Limit alcohol intake as it can fragment sleep later in the night;
  • Create a relaxing atmosphere to reduce anxiety and stress;
  • Take a hot shower shortly before bed;
  • Read or listen to music outside the bed and bedroom;
  • Get into bed only when good and ready for bed - If you are awake in bed for more than 20 minutes after falling asleep get out of bed so that the bed is associated with sleep and sleep alone;
  • Set a routine to wake up daily at the same time to ensure a regular sleep wake rhythm; and
  • Get any sleep disorder, such a sleep apnea, treated to ensure a feeling of wellness and reduce stress!
Dormir, dentro del contexto del bienestar y la resiliencia

Impacto potencial: Poder dormir bien y lo suficiente es fundamental para la salud y el bienestar. Descansar bien de noche también puede ayudar a desarrollar la resiliencia. La resiliencia es un tipo de fortaleza interior que nos ayuda a recuperarnos y superar una situación difícil o estresante. Para mejorar la calidad del sueño en general, es importante que se tomen en cuenta los comportamientos que la empeoran y tratar los problemas, como la apnea del sueño (cuando la respiración para y comienza varias veces mientras duerme), la rinosinusitis crónica (inflamación nasal que puede dificultar la respiración por la nariz) y el trastorno de estrés postraumático (TEPT).

Investigación: Hemos observado que la calidad del sueño no es buena en muchos miembros del personal de respuesta del WTC. Tienen insomnio y dificultad para dormirse y permanecer dormidos. La rinosinusitis crónica, la apnea del sueño obstructiva y el TEPT también pueden contribuir a que esto suceda.

Población: En este estudio se observó a miembros del personal de respuesta, a trabajadores de limpieza y remoción de escombros y a otros trabajadores que estuvieron en el Bajo Manhattan en las semanas y meses posteriores al 9/11.

Hallazgos: La cantidad y calidad del sueño afectan el funcionamiento de las personas durante el día, el estado de ánimo y la calidad de vida en general. La calidad del sueño deficiente, debido al insomnio, la apnea del sueño u otras afecciones, puede debilitar el bienestar y la resiliencia, aumentar los síntomas de ansiedad y depresión, y contribuir a problemas de salud físicos y mentales.

Consejos para mejorar el sueño:

  • Apague todos los dispositivos una hora antes de irse a la cama.
  • Tome solamente bebidas sin cafeína a la noche.
  • Limite la cantidad de bebidas alcohólicas ya que pueden fragmentar el sueño durante la noche.
  • Cree un ambiente relajante para reducir la ansiedad y el estrés.
  • Tome una ducha caliente poco antes de irse a la cama.
  • Lea o escuche música fuera de la cama y de la habitación.
  • V aya a la cama solo cuando esté listo para dormir. Si se había dormido y después se despierta por más de 20 minutos, levántese para que la cama solo esté asociada al sueño.
  • Establezca una rutina para despertarse todos los días a la misma hora y asegurarse de tener un ritmo regular de sueño y vigilia.
  • Busque tratamiento para cualquier trastorno del sueño, como la apnea, para asegurarse una sensación de bienestar y reducir el estrés.
Sen w kontekście dobrej kondycji i odporności

Potencjalny wpływ: Wystarczająca ilość dobrej jakości snu jest niezbędna dla zdrowia i dobrego samopoczucia. Dobry nocny wypoczynek może również pomóc w budowaniu odporności. Odporność to rodzaj wewnętrznej siły, która pomaga dojść do siebie i odeprzeć trudną lub stresującą sytuację. Dla poprawy ogólnej jakości snu ważne jest, aby pozbyć się nieprawidłowych zachowań związanych ze spaniem, które pogarszają jakość snu. Należy leczyć problemy, takie jak bezdech senny (gdy dochodzi do wielokrotnego zatrzymania oddechu podczas snu), przewlekłe zapalenie zatok przynosowych (zapalenie nosa, które może utrudniać oddychanie przez nos) oraz zespół stresu pourazowego (PTSD).

Badanie: Zauważyliśmy, że wielu ratowników WTC cierpi z powodu złej jakości snu. Doświadczają bezsenności oraz problemów z zasypianiem i utrzymaniem ciągłości snu. Przewlekłe zapalenie zatok przynosowych, obturacyjny bezdech senny, a także PTSD, również mogą przyczyniać się do złej jakości snu.

Populacja: Badaniem objęto Ratowników, osoby pracujące przy oczyszczaniu oraz innych pracowników, którzy przebywali na Dolnym Manhattanie w tygodniach i miesiącach po 9/11.

Ustalenia: Ilość i jakość snu ma wpływ na to, jak funkcjonujemy w ciągu dnia, na nasz nastrój i ogólną jakość życia. Kiepska jakość snu spowodowana bezsennością, bezdechem sennym lub innymi chorobami, może pogorszyć samopoczucie i osłabić odporność, nasilić objawy lęku i depresji oraz przyczynić się do długotrwałych problemów zdrowia fizycznego i psychicznego.

Wskazówki, jak poprawić jakość snu:

  • Na godzinę przed pójściem do łóżka wyłącz wszystkie urządzenia;
  • W późnych godzinach wieczornych pij tylko napoje bez zawartości kofeiny;
  • Ogranicz spożywanie alkoholu, ponieważ w nocy może powodować wybijanie ze snu;
  • Dbaj o relaksującą atmosferę, aby złagodzić lęk i stres;
  • Tuż przed snem weź gorący prysznic;
  • Czytaj lub słuchaj muzyki poza łóżkiem i sypialnią;
  • Idź do łóżka dopiero wtedy, gdy jesteś senny i gotowy. Jeśli nie zaśniesz przez ponad 20 minut, wstań z łóżka, aby kojarzyło się ono ze snem. Śpij sam;
  • Wstawaj codziennie o tej samej porze, aby zapewnić sobie regularny rytm snu; oraz
  • Lecz wszelkie zaburzenia snu, takie jak bezdech senny – aby zapewnić sobie dobre samopoczucie i zredukować stres!

潛在影響: 有充足的優質睡眠對於 您的身心健康至關重要。良好的夜間 休息也有助於塑造您的復原能力。復 原能力是一種內在力量,可以協助 您在遇到艱難或緊張的情況時重新振 作並戰勝困難。為了改善整體睡眠, 解決睡眠不良行為極為重要,不良行 為會使睡眠情況更為惡化;治療睡眠 呼吸暫停(睡眠期間呼吸多次停止和 恢復)、慢性鼻竇炎(可能使鼻子呼 吸困難的鼻腔發炎)和創傷後壓力 症 (PTSD)。

研究: 我們已經瞭解到許多 WTC 救 助人員睡眠品質差。他們出現失眠、 無法入睡和睡不安穩等現象。慢性鼻 竇炎、阻塞性睡眠呼吸暫停和 PTSD 也可能導致睡眠品質變差。

人群: 您的睡眠時間長度和睡眠 品質會影響您一整天的身體狀態、心 情和整體的生活品質。由於失眠、睡 眠呼吸暫停或其他健康狀況導致的睡 眠品質差,會削弱您的健康和復原能 力,增加焦慮和抑鬱症狀,並導致長 期的身心健康問題。

研究結果: 您的睡眠時間長度和睡眠 品質會影響您一整天的身體狀態、心 情和整體的生活品質。由於失眠、睡 眠呼吸暫停或其他健康狀況導致的睡 眠品質差,會削弱您的健康和復原能 力,增加焦慮和抑鬱症狀,並導致長 期的身心健康問題。


  • 睡前一個小時關閉所有電子設備;
  • 夜間只喝無咖啡因的飲料;
  • 限制酒精飲用量,因為它可能在 夜間晚些時候影響睡眠;
  • 營造輕鬆的氛圍來減輕焦慮和壓力;
  • 睡前洗熱水澡;
  • 在床和臥室外閱讀或聽音樂;
  • 只有在睏倦並準備好時才上床睡覺 - 如果您在入睡後醒了 20 分鐘以上,請起床,讓床僅與睡眠相關,並且單獨睡;
  • 設定每天醒來的固定時間,以確保有規律的睡眠起床節奏;以及
  • 治療任何睡眠障礙(如睡眠呼吸暫停),以確保健康的感覺,減輕壓力!

Thank you to all who attended the 2017 Research to Care Community Engagement Event on 9/11 Health. Learn more about the World Trade Center Health Program’s Research Projects and Principal Investigators on the WTC Health Program Research Gateway.