FIRE DEPARTMENT, CITY OF NEW YORKBUREAU OFHEALTHSERVICESWTC MEDICALMONITORING& TREATMENTPROGRAMMichael R. Bloomberg, MayorNicholas Scoppetta, CommissionerWORLDORLDTRADERADECENTERENTERHEALEALT HT HIM PM PAACTSCTSO NO NFDNY RESCUEESCUEWORKERSORKERSASix-YearAssessment:September2001-September2007CREDITSFDNY BUREAU OF HEALTH SERVICESKerry Kelly, MD, FDNY Chief Medical Officer, BHSDavid Prezant, MD, FDNY Chief Medical Officer, OMAMary T. McLaughlin, Director, BHSMalachy Corrigan, Director, Counseling Services UnitFDNY WTC MEDICAL MONITORING AND TREATMENT PROGRAMSpencer Carroll, Administrative DirectorJustin Niles, Senior Author and Research AssociateMeryl Perrotta, Associate EditorPublication & PhotosFDNY OFFICE OF PUBLIC INFORMATIONStephen Paul Antonelli, DirectorJanet Kimmerly, Copy EditorThomas Ittycheria, Design/ProductionFDNY BUREAU OF INFORMATION AND TECHNOLOGYJason Cheng, Deputy Director, ProgrammingJohn Adams, Database ManagerKamaldeep Deol, Applications ManagerArumugam Nagappan, Oracle DeveloperReshma Rao, Applications DeveloperPhyllis Vickers, Project ManagerEach year on the anniversary of 9/11, two Towers of Light beam heavenward in commemoration of the 2750 people killed in the attacks on the World Trade Center on September 11, 2001.The Towers of Light stand as a memorial, a symbol of hope and resiliency and a reclamation of New York City’s strength and identity.The purpose of this publication is to share important information the Department has gatheredconcerning the physical and mental health effects of 9/11 on our membership.WORLDORLDTRADERADECENTERENTERHEALTHEALTHIMPACTSMPACTSO NO NFDNY RESCUEESCUEWORKERSORKERSA Six-Year Assessment:September 2001-September 2007Kelly KJ, Niles J, McLaughlin MT, Carroll S, Corrigan M, Al-Othman F, and Prezant D.World Trade Center Health Impacts on FDNY Rescue Workers, A Six-Year Assessment:September 2001-September 2007. Fire Department, City of New York, 2007.Preface:LettersMayor Michael R. Bloomberg . . . . . . . . . . . . . . . .3Fire Commissioner Nicholas Scoppetta . . . . . . . .4Chief of Department Salvatore J. Cassano . . . . . . .5Director of NIOSH Dr. John Howard . . . . . . . . . . .6Bureau of Health Services . . . . . . . . . . . . . . . . . . .7UFA & UFOA . . . . . . . . . . . . . . . . . . . . . . . . . . . .8UEP, UEMSO & SOA . . . . . . . . . . . . . . . . . . . . . . .9Section 1:Introduction & Time Line. . . . . . . . . . . .11Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12History of the FDNY WTC Program . . . . . . . . . . .12Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Time Line:BHS WTC Program. . . . . . . . . . . . . . . . . . .14Section 2:Medical and Exposure Assessment. . .21Medical Questionnaire DataArrival Time at WTC . . . . . . . . . . . . . . . . . . . . . .23Mask/Respirator Use . . . . . . . . . . . . . . . . . . . . . .24Eye and Skin Irritation Post-WTC . . . . . . . . . . . . .25Respiratory Symptoms forDifferent Exposure Groups... . . . . . . . . . . . . . .26Lower Respiratory Symptoms . . . . . . . . . . . . . . . .27Upper Respiratory Symptoms . . . . . . . . . . . . . . . .28Scientific Test ResultsPulmonary Function Loss (by Arrival Time) . . . . . . .29Pulmonary Function Lossby Work Assignment (FIRE & EMS). . . . . . . . . .30Methacholine Challenge TestingHyperreactive Subjects . . . . . . . . . . . . . . . . . .31Disease Surveillance“Sarcoid-Like” Granulomatous Pneumonitis . . . . .322Table of ContentsWorldTradeCenterHealthImpactsonFDNYRescueWorkersSection 3:Mental Health Assessment. . . . . . . . . . . . .33Mental Health Questionnaire DataFDNY WTC Survivors Closely Linked to ThoseLost on 9/11/01 . . . . . . . . . . . . . . . . . . . . . . . .36WTC-Related Health Concerns by Arrival Time . . . . .37WTC-Related Concerns About Early Mortalityby Arrival Time . . . . . . . . . . . . . . . . . . . . . . . . . .37Change in Sleep-Related Issues After WTC . . . . . . . .38Change in Mood After WTC . . . . . . . . . . . . . . . . . .39Feelings of Distance and Detachment After WTC . . . .40Reliving and Remembering the WTC Experience . . . .41Change in Exercise Program After WTC . . . . . . . . . .42Section 4:FDNY Retirement and Disability Data. .43FDNY Retirements and Years of Service. . . . . . . .45Disability Pensions ReceivedNumber of Pulmonary Cases Under the Lung Bill . . .46Number of Permanent PsychologicalImpairment Cases . . . . . . . . . . . . . . . . . . . . . . .47Number of Cardiac Cases Under the Heart Bill . . . .48Number of Cancer Cases . . . . . . . . . . . . . . . . . . . .49NYCERS EMS “3/4” Disability PensionApplications Approved . . . . . . . . . . . . . . . . . . . .50Section 5:The FDNY-WTC-MMTP POST-9/11. . . . . . . .51Number of Monitoring Exams Conducted . . . . . . . . .52Annual Number of Patients in the FDNY-WTCMedical Treatment Program . . . . . . . . . . . . . . . .53Tobacco Cessation Success Rates . . . . . . . . . . . . . .54CSU Provides Counseling and Treatment . . . . . . . . .55Annual Number of Patients in the FDNY-CSUWTC Mental Health Treatment Program . . . . . . . . . .56Section 6:Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57Appendix APublication List . . . . . . . . . . . . . . . . . . . .60Appendix BWellness Self-Tests and Tips . . . . . . . . . . .61Postscript. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64For your doctor--NYC DOHMH Clinical Guidelines forAdults Exposed to the World Trade Center Disaster➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤➤Attachment:3Message from the Mayor of the City of New YorkMichael R. BloombergIn the hours, days, weeks and months following the terrorist attacks on the World Trade Center, New YorkCity Firefighters and emergency services personnel were called upon to make extraordinary sacrifices.Your heroic rescue and recovery efforts, which were the embodiment of selflessness, formed the founda-tion of the City’s post-9/11 rebirth.In the years that have passed since the attacks, the FDNY’s Bureau of Health Services has kept close trackof how work at the site affected rescue workers, physically and emotionally. This report is the result of theirpainstaking efforts to study the long-term effects of the rescue and recovery effort on the people who carriedit out. Hopefully, it will give all of you an overview and a better understanding of how first responders as agroup were, and continue to be, affected. The more information we have about this situation, the better ablewe will be to provide monitoring and treatment to those who need it.In September 2006, I appointed a WTC Health Panel composed of representatives from all City agenciesthat serve or represent individuals affected or potentially affected by WTC-related illnesses. The Panel members were asked to develop recommendations to ensure that WTC health resources are sufficient to providefirst-rate care for everyone whose health was or may be affected by the WTC attacks and their aftermath. ThePanel also was asked to make recommendations to guarantee that City policies regarding WTC-relatedhealth issues are coordinated, comprehensive and responsive to both current and emerging health careneeds. The Panel’s report, “Addressing the Health Impacts of 9/11,” as well as my subsequent testimonybefore the U.S. Senate, stressed the need for federal funding to fully support all WTC-related medical monitoring and treatment programs, including this critical program at FDNY. I accepted all of the Panel’s recommendations, which we are working to implement.This is just one small part of what the City of New York owes to you, our Firefighters and emergency medicalpersonnel. Please know that the herculean efforts carried out by the FDNY’s first responders on 9/11 and inthe months thereafter will never be forgotten.WorldTradeCenterHealthImpactsonFDNYRescueWorkers4When the World Trade Center collapsed on 9/11, it unleashed a cloud of dust anddebris the likes of which this City had never seen before. Among the manyunknowns in the aftermath of that terrible day, one that loomed particularly largewas the question of how that cloud would affect our members’ health. TheFDNY’s Chief Medical Officers, Drs. Kerry Kelly and David Prezant, realized almost immediately after the attack that the short- and long-term effects of exposure to the World Trade Centersite needed to be monitored. Together with a host of partners--from Fire and EMS unions, to theNational Institute of Occupational Safety & Health (NIOSH)--they created a program specifically tailored to the needs of our members. It monitors not only the medical, but also the psychological effects that this catastrophe had, and continues to have, on our first responders.More than 14,200 FDNY first responders have been examined by BHS during the past five years.This report presents the data culled from those examinations in a clear, understandable format.These objective data were an important part of the Mayor’s WTC Health Panel’s deliberationsand recommendations contained in the report, “Addressing the Health Impacts of 9-11.” Theinformation contained in both of these reports will help us not only deliver the health servicesthat best fit our members’ needs, but also help ensure future funding by presenting comprehensive data on our needs.To those who labored at the WTC site, this report comes with a pledge: We will continue to provide our members with the best medical and psychological monitoring and treatment for as longas it is needed.Message from the Fire CommissionerNicholas ScoppettaWorldTradeCenterHealthImpactsonFDNYRescueWorkers5For several long, difficult months after 9/11, thousands of you worked rescue and recov-ery at the site where the Towers had stood and where 343 FDNY members lost theirlives. I witnessed firsthand the many days, nights, weekends and holidays our Firefightersspent there, under physically and mentally grueling conditions. It was a painful time thatnone of us will ever forget. And, unfortunately, it has left us with a lot of questions regarding thelong-term effects on our members.Thankfully, the Bureau of Health Services was there with us from the very beginning. On the veryday of the attacks, they observed first responders suffering a variety of conditions--from eye andskin irritation, to nasal congestion and breathing difficulties. As the weeks and months passed,they continued to monitor and treat our Firefighters and EMS personnel for their physical andpsychological needs.This report is designed to give you an overview of how the World Trade Center first responders,as a group, have been affected medically by their work at the site. More than 14,200 of youcontributed, making this one of the most comprehensive studies done on the subject. Read itcarefully. But remember that it is important to continue your participation in the monitoring program, because having such valuable data will help us secure funding to continue with this workin the future.Thank you all for your dedication to this Department in the aftermath of 9/11. Your sacrificeswill not be forgotten.Message from the Chief of DepartmentSalvatore J. CassanoWorldTradeCenterHealthImpactsonFDNYRescueWorkersDear FDNY Community:Iam pleased to see the important work of the FDNY compiled in this new book. The National Institute forOccupational Safety and Health (NIOSH) has provided funding since 2002 to FDNY for medical screening, mon-itoring and treatment. As Director of NIOSH, I became aware shortly after 9/11 that responders, their familiesand others were deeply concerned with the question of whether exposures to airborne contaminants at GroundZero posed ongoing risks for adverse health effects. It also became clear that robust scientific studies, based on goodclinical assessments, were key for identifying symptoms and trends in health effects that could be used to begin toanswer the question.Since that time, I have had the opportunity to meet many of you who served at Ground Zero.I have been touched by your stories of heroism, hope and faith. FDNY has been a leader in efforts to address thequestions about health effects associated with WTC exposures. Early on, as a partner in federally funded programs,FDNY provided medical screening and monitoring of responders. Those efforts laid the groundwork for subsequentinitiatives to identify trends in illness among FDNY responders, both individually and collectively, to publish scientificstudies that are invaluable for furthering our collective knowledge and to guide treatment. The FDNY program notonly provides needed medical care, it also captures data that will help us develop an accurate picture of the 9/11health outcomes, greatly increasing the ability to identify, prevent and treat illnesses.I am impressed by the quality of the program, as reflected by the contents of this book, and I look forward to continued partnership with you, FDNY, and others to answer the questions that concern us all.Sincerely,Letter from John Howard, MD, DirectorNational Institute for Occupational Safety and HealthCenters for Disease Control and PreventionWorldTradeCenterHealthImpactsonFDNYRescueWorkers6In the aftermath of 9/11, the health consequences to our FDNY members (Fire and EMS) were both immediateand far-reaching. In the hours after the collapses, members fought to survive while working to find lost coworkersand civilians. They struggled to breathe particle-laden air and to clear eyes, noses and mouths of fallen debris.The fires continued to burn until December of 2001. Our Department, carrying out its rescue, recovery, emergencymedical care and fire suppression roles, maintained a continuous presence at the site until its closure in July 2002.Our rescue workers were the first in, the last out and the most exposed, working at the deepest levels.The need to evaluate and monitor the health effects of this exposure was evident early on. That is why the Bureau ofHealth Services, with the help of labor and management, developed this program, which began in October 2001,just weeks after 9/11. This report is an outgrowth of that work; although there are still many unanswered questions,it gives us the chance to share what we do know at this point in time.Some of the information gathered comes from comprehensive medical questionnaires, some from testing, some fromFDNY retirement statistics and some from the FDNY’s Counseling Services Unit. We also have included in this bookthe NYC Department of Health and Mental Hygiene Clinical Guidelines for Adults Exposed to the WTC Disaster. Weask that you bring it to your personal doctor to assist in caring for your health.This report can only begin to address the question raised by many of our rescue workers: “How are we doing”? Theinformation we gather from this program will help us answer this question, both now and in the future. We owe it toall our members to share all information we gather and analyze. We know that without the participation of our membership, this program could never succeed.The need remains for long-term monitoring of both active and retired Firefighters and EMS members, not only toexamine current medical issues, but also to look for any late-emerging symptoms or diseases that could occur in thefuture. We remain committed to providing evaluations and treatment for the physical and mental health consequencesof WTC exposure for our exposed members. Obtaining the resources to fully fund this program, provide these services and share this information have been and will continue to be among our top priorities.Be well, stay safe and continue to take care of yourselves and your families.Message from the Bureau of Health ServicesWorldTradeCenterHealthImpactsonFDNYRescueWorkers7Dr. David PrezantDr. Kerry KellyDr. Kerry Kelly Dr. David PrezantChief Medical Officer, BHS Chief Medical Officer, OMA8Letter from Firefighting UnionsWorldTradeCenterHealthImpactsonFDNYRescueWorkersDear UFA and UFOA Members:Words cannot capture our experiences on 9/11/01 and in the days, weeks and months thereafter. We lost343 of our Brothers. We do not want to lose one more. Most of us--some for many months--served at theWTC site, the Fresh Kills landfill or the Medical Examiner’s office. Although we cannot change the exposureswe experienced, we can improve our health through medical monitoring and treatment.Within a month of the 9/11 attacks, BHS initiated comprehensive medical screenings for FDNY members. We worked withBHS in designing the FDNY BHS World Trade Center Medical Monitoring and Treatment Program specifically for our members. Your periodic annual medicalisthe World Trade Center medical for those Firefighters who were on the job on9/11/01. Together--the City, FDNY, BHS, IAFF, UFA and UFOA and our fellow unions--successfully advocated for fundsfrom the United States Congress for long-term medical and mental health monitoring and treatment.We urge all members exposed on 9/11 and in the aftermath to participate in the FDNY BHS World Trade Center MedicalMonitoring and Treatment Program. The program has been expanded to include treatment for all WTC-related symptoms.The program includes diagnostic testing, outside counseling referrals andfree medications for WTC-related conditions.BHS continues to schedule active and retired members for repeat, follow-up exams every 12 to 18 months.This book on the medical and mental health impacts of 9/11 provides valuable information and guidelines for every member, their families and their health care providers. We strongly recommend that you thoroughly review this important information. If you have questions after reading the book, please bring them to your health care providers. Take the enclosedWTC diagnosis and treatment guidelines to your personal physician.We are grateful to BHS for its insight, vision and dedication to protecting our members’ health. Both unions continue toserve as active and voting members on the World Trade Center Medical Monitoring and Treatment Program SteeringCommittee. We look forward to our continued collaborative efforts. We thank our members for their honorable service.We wish you all the very best health--today, tomorrow and in the future.Sincerely,Stephen J. Cassidy John J. McDonnellUFA, Local 94 UFOA, Local 854Stephen J. CassidyJohn J. McDonnell9Letter from EMS UnionsDear EMS Members:Your heroic actions on 9/11/01 and your dedication in the months that followed will never be forgotten. Wealso will never forget our two lost members. We thank you for making us proud.From the onset, we worked together with FDNY-BHS to design a medical examination specifically for our members.Together with the City, FDNY, UEP, UEMSO, SOA, AFSCME, AFL-CIO and our fellow unions, we were able to securefunds from the United States Congress to provide periodic comprehensive medical monitoring and treatment throughthe World Trade Center Medical Monitoring Program.Active members receive this comprehensive medical as part of their annual physical examination. Retirees have beenand will continue to be contacted for follow-up WTC Medical Monitoring. This program provides valuable surveillance and resources for diagnostic testing, respiratory and mental health treatment andfree medications for WTCrelated conditions.This book sheds light on the medical and mental health impacts during the first five years since 9/11/01. Read itthoroughly. Share it with your health care providers. Inform the program administrators and your health care providerof any changes in your health status. Take the enclosed WTC diagnosis and treatment guidelines to your personalphysician.We urge all members who were exposed at the World Trade Center site to continue to participate in the WTC MedicalMonitoring Program every 12 to 18 months. Both UEP and UEMSO continue to serve as active and voting memberson the World Trade Center Monitoring and Treatment Program Steering Committee. Supporting this program is oneof the most important things we can do to protect the health and safety of our members for the foreseeable future.Sincerely,Patrick Bahnken Thomas Eppinger Mark SteffensUEP, Local 2507 UEMSO, Local 3621 SOAWorldTradeCenterHealthImpactsonFDNYRescueWorkersPatrick BahnkenMark SteffensThomas Eppinger10WorldTradeCenterHealthImpactsonFDNYRescueWorkersFDNY Ceremonial Unit member at the September 11, 2006,World Trade Center Memorial Ceremony.SECTION 1INTRODUCTION & TIME LINEMission➤History of the FDNY WTC Program➤Funding➤12WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 1INTRODUCTIONDuring the past five years, FDNY’s World Trade CenterMedical Monitoring and Treatment Program (FDNY-WTC-MMTP) has become a national model in termsof both providing services for Department membersand developing comprehensive data on the effects of exposureto the WTC site. These objective data were an important part ofthe Mayor’s WTC Health Panel’s deliberations and recommendations released in February 2007. Through a series of chartsand graphs, our FDNY report presents the data we haveobtained. We hope this information is useful to all of our members, including non-WTC responders, in understanding theknown health effects of 9/11. Of course, this FDNY report presents only aggregate data and contains no information aboutany individual member’s health. In performing its medical monitoring and treatment roles, the FDNY-WTC-MMTP, as a top priority, is preserving the confidentiality of members’ personalhealth records and information.Section 1 of this report provides some background on theFDNY-WTC-MMTP (hereafter referred to as “the FDNY WTCProgram”). Section 2 presents aggregate data on the physicalhealth effects of exposures at the WTC on and after 9/11.Section 3 presents aggregate data on the mental health effectsof 9/11. Section 4 shows the effects of 9/11 on FDNY memberretirements and disability pensions collected. Sections 5 and 6provide a summary of efforts to date, a brief look at future plansand information about funding the FDNY’s programs.TheAppendices provide useful additional informationabout treatment centers, self-evaluation tips aboutyour potential need for treatment and a list of FDNYWTC publications.MISSIONThe current mission of the FDNY WTC Program is to evaluate and treat individual FDNY members, both active andretired, who worked at the WTC sites. The FDNY WTC Programdevelops plans for future monitoring and treatment needs byanalyzing patterns of illness and using this information toanswer central questions about the health effects of WTC exposure. Monitoring and treatment are an outgrowth and expansion of what the FDNY Bureau of Health Services (FDNY-BHS)does everyday--improving member health and wellness throughperiodic medical evaluations, preventive therapies, injury/illnessevaluations and treatment.HISTORY OF THE FDNY WTC PROGRAMOne month after the attacks on the WTC, under the guidance of our Chief Medical Officers, Dr. Kerry Kelly and Dr.David Prezant, FDNY-BHS began comprehensive medicalscreenings. Both doctors were caught in the collapse andunderstood the potential short- and long-term health impacts ofthe unique exposures experienced at the WTC sites by ourFDNY rescue workers (Firefighters and EMS members). FDNYBHS co-designed this program specifically for FDNY members,partnering with the Uniformed Firefighters Association (UFA), theUniformed Fire Officers Association (UFOA), the InternationalAssociation of Fire Fighters (IAFF) and Uniformed EmergencyMedical Technicians and Paramedics (UEP), Uniformed EMSOfficers (UEMSO) and the Supervising Officers Association(SOA).The periodic medicals and treatment programs already inplace for active members supplied the foundation for the FDNYWTC Program and enabled FDNY-BHS to institute the programrapidly. We are proud that our BHS physicians were the first toidentify and treat WTC-related illnesses and that the FDNY WTCProgram helped to inform other WTC medical programs,including those provided by the Mount Sinai Consortium’s1WTC Medical Monitoring and Treatment Program for nonFDNY responders and the Bellevue Hospital WTC13SECTION 1 • INTRODUCTIONWorldTradeCenterHealthImpactsonFDNYRescueWorkersEnvironmental Health Center’s Treatment Program.Recognizing the potential for long-term health consequencesfrom the exposures experienced at the WTC site, the FDNY WTCProgram expanded its initial screening programs to includelong-term monitoring, disease surveillance for late-emergingproblems and treatment. Over time, the FDNY WTC Programalso included many scientific partners, including the Centers forDisease Control and Prevention (CDC), the National Institute forOccupational Safety and Health (NIOSH), the Mt. Sinai NY/NJWTC Health Consortium for non-FDNY responders, the BellevueHospital WTC Environmental Health Center, Montefiore MedicalCenter and Albert Einstein College of Medicine. As of December31, 2006, more than 14,200 FDNY WTC rescue workers havehad medical monitoring examinations and more than 8000have received follow-up monitoring exams. Outreach activitiescontinue in an effort to give monitoring examinations to all ofthe approximately 16,200 members with whom the FDNY WTCProgram has been in active contact.The FDNY WTC Program recently has expanded to provideWTC-related medications to active and retired members. Thevarious treatment options available in the program will be discussed in greater detail later in this publication. Treatment provided under the FDNY WTC Program includes services only forWTC-related conditions. For those who did not participate in theWTC rescue and recovery effort and are not eligible for thesefree medications, the FDNY WTC Program remains importantbecause it has allowed FDNY to provide increased monitoring,expanded treatment options, improved safety benefits and morerobust training programs to all members.FUNDINGIn October 2001, only four weeks after the attack, FDNYBHS began performing standardized medical screenings onWTC rescue workers with funding provided by NYC and theFDNY. This was the first comprehensive post-WTC exposuremedical performed by any medical institution. In November2001, the CDC granted $4.8 million to the FDNY to help fundthis program from 2002 to 2004. This allowed the FDNY WTCProgram to include affected retirees, who previously would havebeen excluded from BHS monitoring and treatment. By February2002, FDNY-BHS had conducted screening medical examinations on nearly 10,000 FDNY rescue workers (Fire and EMS,active and retired).In July 2004, the FDNY received $25 million fromCDC/NIOSH to expand its monitoring program for an additional five years (2004-2009). This funding pays for standardizedclinical exams, staffing, scheduling and follow-ups. With thisfunding, every “annual” or periodic medical evaluation members receive at the FDNY has been improved and expanded tobe a WTC periodic medical to include higher quality pulmonaryfunction tests and improved medical and mental health questionnaires. It also supports an FDNY data management group toprovide quality assurance and data analysis, so that the FDNYWTC Program can plan for future needs and release its findingsto our members. This report, provided to every active FDNYmember and affected retiree, is one example of the data management group’s work.The FDNY WTC Program receives funding from the FDNY toprovide most work-related treatment for our active members.Since 2005, certain specialized WTC treatments have been provided by supplemental funding through a September 11thRecovery Grant from the American Red Cross (ARC) LibertyDisaster Relief Fund. For retirees, initial funding for WTC-relatedphysical health treatment (respiratory, etc.) came from this ARCgrant. For retirees and family members, funding for WTC-related mental health treatment has come from multiple sources,1Hospitals in the Mount Sinai Consortium:• Mount Sinai School of Medicine/I. J. Selikoff Center for Occupationaland Environmental Medicine• Long Island World Trade Center Monitoring and TreatmentPrograms/Stony Brook Medical Center• Center for the Biology of Natural Systems, Queens College• University of Medicine & Dentistry of New Jersey/Robert WoodJohnson Medical School, Environmental & Occupational HealthSciences Institute• Bellevue Hospital Center/NYU School of Medicineincluding the FDNY, IAFF, ARC, FEMA--Project Liberty,SAMSA and various philanthropies. A recent(November 2006) influx of approximately $20 millionfrom the federal government (NIOSH) now is beingused to continue these medical and mental healthtreatment efforts. We anticipate that this funding willsupport the program for approximately 12 months.The FDNY continues its efforts to secure additionalfederal funding to provide members with continuedlong-term monitoring and expert treatment. Futurefederal funding is always contingent upon documented needs; therefore, member participation in theFDNY WTC Program is important.The FDNY and its unions have been major supporters of this program. Every dollar we receive from thefederal government for the FDNY WTC Program isspent only on this program. Both the FireCommissioner and union leadership have been instrumental in helping FDNY-BHS obtain funding for theFDNY WTC Program.City government also has played a crucial role. InSeptember 2006, the WTC Health Panel was formedto make recommendations to ensure sufficient fundingof WTC health programs in the future. Its report,“Addressing the Health Impacts of 9-11,” and the subsequent testimony given by Mayor Bloomberg beforethe U.S. Senate, vigorously advocate federal fundingto fully support the FDNY WTC Program, the MountSinai Consortium’s WTC Medical Monitoring andTreatment Program for non-FDNY responders and theBellevue Hospital WTC Environmental Health Center’sTreatment Program.14WTC AttacksTower 1 and 2 collapseTotal job recallBHS sets up triage center onBroadwayTower 7 collapseBHS treats members for WTCsymptoms & injuriesCSU support groups begin,debriefing groups at siteIAFF and NFFF assist FDNY-CSUCSU sets up units in StatenIsland and Fort Totten,QueensDr. Kelly testifies before U. S.Congress on WTC healthimpactDr. Prezant addresses IAFFConvention on WTC healthimpactNY Daily News,Sept. 27th. “Fire Doc CitesNightmare of Bravest”FDNY becomes Project Liberty mentalhealth siteWTC Medicals begin 7 days a week,3 shifts per dayBHS and CDC partnership to test forheavy metals, PCBs and PAHsBHS identifies “WTC CoughSyndrome”FEMA and Project Liberty fundingarrive for CSUCongressional Committee hearingson 9/11NY Times, Oct. 30th. “A NationChallenged: The Firefighter’sRampant Coughs and Chest PainAmong Workers at Ground Zero”NY Newsday, Oct. 30th. “The Waron Terror; Breathing uneasily; respiratory problems plaguing Firefighters”NY Daily News, Oct. 30th.“Firefighters battle ‘Trade CenterCough’; 4,000 report problemslinked to dust & smoke”FDNY awarded$4.8 million fromCDC for medicalscreening for years1 and 2Fires at WTCsuppressed2002Dr. Prezant andSenator HillaryClinton at joint pressconference to secure$12 millionDr. Kelly addressesNY CongressionalDelegation on 9/11health effectsNY Daily News,Jan. 20th. “TerrorAttacks Take HiddenToll: PosttraumaticStress hits Finest,Bravest”BHS completesmore than 10,000WTC ScreeningMedicals onFDNY membersWTC ScreeningMedicals continue5 days a week,one shift per dayBHS WTC PROGRAM TIME LINE—September 2001-April 2007WorldTradeCenterHealthImpactsonFDNYRescueWorkersBHS Programs/ActivityBHS Press ClippingsBHS Published Scientific Articles

SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY200115WorldTradeCenterHealthImpactsonFDNYRescueWorkersNY Daily News,March 4th.“Retiring from theHorror Post-9/11job stress thinningout Bravest &Finest”NY Daily News,March 24th. “NYFirefighters Strugglewith BreathingProblems”Dr. KellyaddressesCongressionalCommittee onEnvironmentalConservation,Health andLaborBHS gives testimony at NY Academy ofMedicine Specialists WTC MeetingMMWR, Sept. 11th. “Injuries and IllnessesAmong New York City Fire Department RescueWorkers After Responding to the World TradeCenter Attacks”MMWR, Sept. 11th. “Use of RespiratoryProtection Among Responders at the WorldTrade Center Site--New York City, September2001”New England Journal of Medicine, Sept. 12th.“Cough and Bronchial Responsiveness inFirefighters at the World Trade Center Site”NY Daily News, Sept. 9th. “LIGHTS OUTEmbracing Life, city firefighters enroll in a newanti-smoking program. Quitting Time forFDNY Firefighters”NY Times, Sept. 10th. “Threats andResponses: Rescuers Health: Lung AilmentsMay Force 500 Firefighters off job”NY Newsday, Sept. 10th. “Report: ManySapped by ‘WTC Cough’; Hundreds on medical leave, restricted to light duty”Joint labormanagementinitiative forWTC CD 73ExposureReportsSince9/11/01,1000 clientsat BHS forrespiratorytreatmentSince9/11/01,4000 clientshave cometo CSUNY DailyNews,Dec 15th.“WTC Study:Workers StillGasping forAir; half ofscreened rescuers sufferailments”BHS HealthConnectionsnewsletter debutsOctober 12thMemorial DayService. Plaquededication andMedalCeremony atMadison SquareGardenNY Newsday,Oct. 1st.“Assessing thescope of WTCailments: Expertsstudy how lungills may worsen”

MARCH APRIL JULY SEPTEMBER OCTOBER NOVEMBER DECEMBER2002WTC site officiallyclosesFDNY work officiallyends at the WTC siteFDNY Free TobaccoCessation Programbegins, supported byPfizer, IAFF, ACCPand ChestFoundationAmerican Journal ofRespiratory andCritical CareMedicine,July 2002.“Acute EosinophilicPneumonia in a NewYork City FirefighterExposed to WorldTrade Center Dust”NY Newsday, July30th. “Clinton:Release $90M forCheckups”BHS WTC PROGRAM TIME LINE—September 2001-April 200716NY Daily News,January 24th. “He'llHear from Bravest.They want 9-11 aidfrom Bush at Stateof Union” JANUARYAm. J. Resp. Crit.Care Med., February2003. “PersistentHyperreactivity andReactive AirwayDysfunction inFirefighters at theWorld Trade Center”

FEBRUARYNY Daily News,May 25th. “Sept. 11Horror HauntsHeroes: physical,mental trauma surfacing” MAYFirst anniversary ofTobacco CessationProgram--more than600 members andfamilies treated witha 50% success rate

JULYIAFF Annual HealthConvention--WTCHealth EffectsEnvironmental HealthPerspectives,September 2003.“Biomonitoring ofChemical Exposureamong New YorkCity FirefightersResponding to theWorld Trade CenterFire and Collapse”

SEPTEMBEROctober 15th. FirstBioPOD exercisesuccessfully completedRetired members arewelcomed back forWTC follow-up medicalsDr. Weiden testifieson WTC Health offirst responders toCongress OCTOBERJames E. OlsenFoundation providesBHS w/10,000colon cancerscreening kitsFDNY, 2003.“Rising to theChallenge: TheCounseling ServiceUnit of the FireDepartment of NewYork Moves ForwardAfter September 11,2001” DECEMBER2003WorldTradeCenterHealthImpactsonFDNYRescueWorkersBHS Programs/ActivityBHS Press ClippingsBHS Published Scientific ArticlesBHS WTC PROGRAM TIME LINE—September 2001-April 200717WorldTradeCenterHealthImpactsonFDNYRescueWorkersSecond BHS9/11BehavioralHealthScreen sentto UFOAmembersand UFAretireesSmallpoxVaccinationProgrambegins forhealth careworkers andfirst respondersNY DailyNews, May24th. “1,700Sue Over9-11 SicknessBravest, Finestcite work atWTC andFresh Kills”November 11th.Second AnnualBioPOD exercisesuccessfully completedNIOSH WTCMedical MonitoringSteering CommitteebeginsJoint labor-management partnership with FDNY andMt. Sinai NY/NJWTC HealthConsortium, including BellevueHospitalEnvironmentalHealth Perspectives,November 2004.“Induced SputumAssessment in NewYork CityFirefighters Exposedto World TradeCenter Dust”9/11 WorldTrade CenterHealth EffectsConference atNYUDr. Prezantspeaks on“Airway andLung Diseaseamong FDNYFirefighters”Dr. Kellyspeaks on“Mental Healthof FDNYFirefighters”

JANUARY MARCH APRIL MAY SEPTEMBER NOVEMBERAmerican RedCross LibertyDisaster ReliefSeptember 11thFund RecoveryGrant--$5.6 million for FDNYBHS WTCMedicalTreatment (7/05-7/07)Crit. Care Med.,June 2005.“Bronchial hyperreactivity andother inhalationlung injuries inrescue/recoveryworkers after theWorld TradeCenter collapse”Curr. Opin.Pulm. Med., June2005.“Pulmonary disease in rescueworkers at theWorld TradeCenter site”FDNY-BHSbeginsEnhancedWTCMedicalMonitoringVersion 2BHS beginsincreasingstaff size forenhancedmedicalsFDNY-BHSHurricaneKatrinarelief preand postdeploymentmedicals5600 invitational letters toretirees torejoin theWTCMedicalMonitoringProgramNovember10th. ThirdAnnualBioPODexercisesuccessfullycompleted20042005$90 millionfederal grantfor WTCConsortium--$25 million toFDNY-BHS formedical monitoring for 5years (2004-2009)Chest, April2004.“Symptoms,Respirator Use,and PulmonaryFunctionChangesAmong NewYork CityFirefightersresponding tothe World TradeCenterDisaster”BHS WTC PROGRAM TIME LINE—September 2001-April 2007 JUNE AUGUST SEPTEMBER NOVEMBER18WorldTradeCenterHealthImpactsonFDNYRescueWorkersFDNY Commissionermeets key Congressionalmembers for WTC medical fundingThe Chief, January20th. “Link Deaths of 3Firemen, Cop to WTCSite; Health officials UrgeScreening, Offer FreeTreatment”The Chief, January27th. “Unions Call forDeath benefit in Post9/11 Cases; Wary ofGrowing Toll Amongresponders to WTC Site”

JANUARYDr. Kelly andDr. Prezant testify beforeCongress for WTC treatment dollarsRetiree WTC MedicalMonitoring Program officially beginsNY Daily News, Feb.19th. “Clear the Air on9-11 Health” FEBRUARYBHS World Trade CenterMedical MonitoringProgram WebsitelaunchedDr. John Howard namedCoordinator of WTCPrograms, announcesmulti-million-dollar federal grant will be awarded in late 2006 forFDNY BHS to expandWTC treatmentNY Post, March 9th.“$75M fund to treat9/11 Cops and Firemen”

MARCHChest, April 2006.“Tobacco Free withFDNY” The New YorkCity Fire DepartmentWorld Trade CenterTobacco Cessation Study

APRILNY Times, May 2nd.“‘Teachable’ 9/11Moment Helped SmokersQuit”NY Post, May 15th.“Heroes’ Breath toll--9/11 Sucks 12 Yearsfrom Bravest Lungs”NY Times, May 16th.“Firefighters’ LungCapacity Suffered after9/11 Work, Study showsabout 10 times usualloss”NY Post, May 22nd.“Medics Kids MostShaken After 9/11”

MAYNY Newsday, June1st. “The RespondersHealth Woes: Their9/11 Plague: Almost 5years after the terrorattacks, new, criticalcases are surfacing”

JUNE2006BHS Programs/ActivityBHS Press ClippingsBHS Published Scientific ArticlesBHS WTC PROGRAM TIME LINE—September 2001-April 200719WorldTradeCenterHealthImpactsonFDNYRescueWorkersDr. John Howard, NIOSHDirector and WTC HealthCoordinator, visits FDNYBHS siteNY Daily News, July22nd. “AbandonedHeroes”NY Daily News, July23rd. “The FatalitiesAmong the Forgotten”NY Daily News, July24th. “Death Sentence”NY Daily News, July27th. “Proof of lung woesDocs detail pain of WTCworkers” JULYMore than 1100 retireesreceive WTC monitoring medical in first 6 months.FDNYreceives $1.5 million fromNIOSH to continue CSU treatment centersAm. J. Resp. Crit. Care Med.,August 2006. “PulmonaryFunction After Exposure to theWorld Trade Center in the NewYork City Fire Department”Editorial published in Am. J.Resp. Crit. Care Med., August2006; 174:235. The WorldTrade Center Collapse AContinuing Tragedy for LungHealth? By Balmes J.R.NY Newsday, August 2nd.“Study: 9/11 responders lungsimpaired”NY Post, August 9th. “FDNYto Take Closer Look atHeroes’ Health”The Chief, August 11th.“Cites Impact on Health:Clinton: Feds must help 9/11workers” AUGUST5th Anniversary ofSeptember 11thDOHMH WTCClinical TreatmentGuidelines forAdults Exposed toWTC (FDNY andMount Sinai coauthors)Comm. Scoppettatestifies at U.S.Congress on WTChealth effects Sept.8thMayorBloombergforms WTCHealth Panel SEPTEMBERFDNY receives$20 millionsupplementfrom NIOSH tobegin free medication programand expandtreatment NOVEMBERBHS beginsWTC treatmentwith free medications DECEMBER2006 & 2007BHS WTC PROGRAM TIME LINE—September 2001-April 2007February 13th. Mayor’sWTC Panel releasesreport, “Addressing theHealth Impacts of 9/11”;outlines annual healthand mental health treatment and monitoringrecommendationsDeputy Mayors LindaGibbs and Edward Skylergive testimony to U.S.CongressMarch 21st. MayorBloomberg testifiesbefore U.S. Senate forWTC treatment programsChest, April 2007. “WTCSarcoid-LikeGranulomatousPulmonary Disease inNYC Fire RescueWorkers” FEBRUARY MARCH APRIL20Aerial view of Ground Zero during recovery operations phase.WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2MEDICALANDEXPOSURE ASSESSMENTMedical Questionnaire Data◆Arrival Time at WTC➤Mask/Respirator Use➤Eye and Skin Irritation Post-WTC➤Respiratory Symptoms for Different Exposure Groups➤Lower Respiratory Symptoms➤Upper Respiratory Symptoms➤Scientific Test Results◆Pulmonary Function Loss (by Arrival Time)➤Pulmonary Function Loss by Work Assignment (FIRE & EMS)➤Methacholine Challenge Testing Hyperreactive Subjects➤Disease Surveillance◆“Sarcoid-Like” Granulomatous Pneumonitis➤22WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2MEDICALANDEXPOSURE ASSESSMENTOn 9/11/01, BHS physicians immediatelyresponded to the WTC. They were presentduring and after the collapse, seeing first-hand how FDNY rescue workers sufferedfrom eye and skin irritation, nasal drip/congestion,coughing, breathing difficulties and other respiratorysymptoms. The medical screening program developed byFDNY-BHS four weeks after 9/11 evaluated and monitored these symptoms in our first responders.Members had blood tests administered, includingcomplete blood cell counts, chemistries, lipid profiles,heavy metal screening and urine analysis. The blood andurine samples from the first 321 FDNY rescue workerswere sent to the CDC’s National Laboratory to test formore than 110 chemicals, including heavy metals, polyaromatic hydrocarbons, PCBs and dioxins. These testsshowed no clinically significant elevations and, therefore,bio-monitoring tests on the rest of our group (more than13,600 additional members) concentrated on certainhighly toxic heavy metals (lead, mercury and beryllium)and total PCBs. Testing found heavy metals to be withinnormal clinical limits for all of our members and totalPCBs to be within normal limits for nearly all. In a groupof approximately 50 Firefighters, PCB tests showed mildelevations.The initial post-9/11 medical evaluation also includeda chest x-ray, pulmonary function testing, EKG, hearingevaluations and a physical by our Medical Officers. Ateach medical, FDNY rescue workers also participated inan educational presentation with a question/answer session that reviewed WTC-related physical and mental healthchallenges, stress recognition and coping strategies.To assess the long-term physiological and psychologi-cal impacts of 9/11 on rescue workers and their families,the WTC Program developed a series of self-administered,computerized questionnaires, in conjunction with periodicmedical interviewing and testing of active members andretirees. The initial questionnaire was conducted fromOctober 2001 to October 2002 and then was replacedwith an updated questionnaire that ran from October2002 until August 2005. The total number of membersresponding was 9953 in the first year and more than14,200 cumulatively as of December 31, 2006. In thefuture, we will strive to give monitoring examinations toall 16,200 members with whom we have been in contact.Responses have been analyzed for the October 2001to August 2005 period. We are continuing to compilesimilar data from August 2005 to date, using newer ver-sions of the computerized questionnaire. We have had anunprecedented response that clearly reflects our mem-bers’ recognition of the importance of the FDNY-WTCProgram and their active participation. We hope that ourmembers will continue to participate, as the informationwe gain helps us to deliver the health services that best fitour members’ needs. The results of these questionnaires,as shown on the following pages, indicate that manyWTC-related symptoms and conditions (respiratory andmental health) are strongly tied to arrival time at the WTCsite.The information contained in Section 2 has beengathered from medical questionnaires taken byactive and retired FDNY members at the FDNYBureau of Health Services during medical monitor-ing evaluations administered post-WTC. ActiveFDNY members were asked to respond to thequestionnaire at their periodic company medical,which now includes the WTC medical.23SECTION 2 •MEDICAL QUESTIONNAIRE DATAWorldTradeCenterHealthImpactsonFDNYRescueWorkersIn an effort to better understand the health effects of Ground Zero exposure onFDNY employees, we classified rescue workers into four groups, based on theirestimated arrival times at the WTC site.1➤Arrival Group I1858 FDNYrescue workers present at WTC onthe morning of 9/11/01 during thecollapse➤Arrival Group II9435 FDNYrescue workers who first came tothe WTC site in the afternoon ofDay 1 or anytime on Day 2➤Arrival Group III2031 FDNYrescue workers who first came tothe WTC site on Day 3 or later➤Unexposed Group187 FDNYrescue workers with no presence, atanytime, at the WTC siteNinety-nine percent of the group surveyed responded to the WTC. There was a job-wide recall that brought in activemembers. In addition, many retired members volunteered and that response continued for the weeks and months tocome. In the initial trauma of that day, our injured members were taken to local hospital centers (including locationsin New Jersey), most with significant orthopedic injuries and a few with severe respiratory injuries requiring mechanical ventilatory support. Members critically injured by falling debris required hospitalization and, for some, orthopedicsurgeries to recover. In the first 24 hours, 240 FDNY members were treated in emergency departments and 28 members were admitted to hospitals. Some members had respiratory difficulties that began that day, but for many others,respiratory symptoms surfaced in the days, weeks and months after 9/11/01.1Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.ARRIVAL TIME AT WTCFDNYRescueWorkers16,00014,00012,00010,00080006000400020000Total Deceased ArrivalGroup IArrivalGroup IIArrivalGroup IIIUnexposedGroup3432.5%13,854943568.1%185813.4%203114.7%1871.3%24WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2 •MEDICAL QUESTIONNAIRE DATA* A respirator is a specially fitted device worn over the mouth and/or nose that protects the respiratory system of the user.2Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Oct. 2002.Frequency of mask and/or respirator* use is a prominent factor consideredwhen determining the severity of the exposure experiencedby WTC rescue workers.2When the towers collapsed, an enormous dust cloud with a high concentration of particulate matter consumedlower Manhattan. FDNY first responders constantly inhaled this thick air, a process made worse by strenuous workand open-mouth breathing. On Day 1, even those with self-contained breathing apparatus (SCBA) only had clean airfor about 15 minutes. After the SCBAs ran out of air and for the many who did not have an SCBA, there were fewrespirators available to rescue workers and those who used protection wore dust masks. N95 “TB” respirators are correct for biological emergencies; however, dust, surgical masks and N95 “TB” respirators do not provide adequate respiratory protection at a collapse/fire disaster site. The correct mask for this exposure (P-100 respirator) was not widely available until after the first week. The intense environmental exposure is directly related to the respiratory symptoms/illnesses described throughout this publication.Day 1➤56% never wore a mask/respirator➤23% rarely wore a mask/respirator➤21% mostly wore a mask/respiratorDay 2➤47% never worn➤23% rarely worn➤30% mostly wornWeeks 2-4➤12% never worn➤19% rarely worn➤69% mostly wornAfter Oct. 1, 2001➤9% never worn➤16% rarely worn➤75% mostly wornMASK/RESPIRATOR USE100806040200Day 1 Day 2 Wk. 2-4 After 10/1/01NoneWorn RarelyWorn Mostly

F D N Y W T C R e s c u e W o r k e r s ( % )25SECTION 2 •MEDICAL QUESTIONNAIRE DATAWorldTradeCenterHealthImpactsonFDNYRescueWorkersThe number of rescue workers suffering from eye and skin irritation hasdecreased dramatically as time has progressed.3One Month Post-WTC➤70% of rescue workers hadeye irritation➤30% had skin irritationOne Year Post-WTC➤47% had eye irritation➤25% had skin irritationYears 2-4 Post-WTC➤7% had eye irritation➤4% had skin irritationEye and skin irritations were likely to occur when exposed to the thick dust cloud, as evidenced by the highrates of these symptoms in the first months after 9/11/01. There has been a dramatic decline in the incidenceof both types of irritation in years 2-4. Currently, few continue to report eye and skin symptoms.3Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.

F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC mo. 1Post-WTC yr. 1Post-WTC yrs. 2-4Eye Irritation Skin Irritation80706050403020100EYE AND SKIN IRRITATION POST-WTC26WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2 •MEDICAL QUESTIONNAIRE DATA4Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Oct. 2002.The incidence of respiratory symptoms in the first year after 9/11/01is directly related to WTC arrival time.4In total, more than 79 percent of those present during the morning of 9/11/01 had at least one lower respiratorysymptom, with a large number demonstrating multiple symptoms. Our data show a strong connection between WTCexposure and respiratory ailments. These data clearly indicate that earlier arrival times (especially within the first 48hours) at WTC by FDNY members are associated with the highest incidence rate for respiratory symptoms.Other scientific groups have mirrored our results, showing a clear association between arrival time and loss of pulmonary function.Daily Cough➤54% of Arrival Group I➤47% of Arrival Group II➤31% of Arrival Group IIIShortness of Breath➤38% of Arrival Group I➤25% of Arrival Group II➤14% of Arrival Group IIIWheezing➤27% of Arrival Group I➤20% of Arrival Group II➤12% of Arrival Group IIIChest Pain➤30% of Arrival Group I➤20% of Arrival Group II➤10% of Arrival Group IIIAny of these Symptoms➤79% of Arrival Group I➤69% of Arrival Group II➤50% of Arrival Group III100806040200Daily Cough Short of Breath Wheeze Chest Pain Any LowerRespiratorySystemArrivalTimeExposureCategoryGroup I=AM of 9/11/01Group II=Next 36 hours (Day 1 PM & Day 2)Group III=After Day 2

F D N Y W T C R e s c u e W o r k e r s ( % )RESPIRATORY SYMPTOMS FOR DIFFERENT EXPOSURE GROUPSYEAR 1Arrival Group IArrival Group IIArrival Group III27SECTION 2 •MEDICAL QUESTIONNAIRE DATAWorldTradeCenterHealthImpactsonFDNYRescueWorkersWith early diagnosis and treatment, the incidence rate of lower respiratorysymptoms has declined significantly since 9/11/01, but these symptoms persistin many of our members.5Day 1 9/11/01➤99% of FDNY rescue workers present were coughing➤43% had shortness of breath➤30% were wheezing➤36% had chest painMonth 1 Post-WTC➤53% had a daily cough➤29% had shortness of breath➤21% were wheezing➤24% had chest painYear 1 Post-WTC➤46% had a daily cough➤25% had shortness of breath➤20% were wheezing➤20% had chest painYears 2-4 Post-WTC➤31% had a daily cough➤28% had shortness of breath➤20% were wheezing➤11% had chest painDay 1 exposure to clouds of dust and debris resulted in cough symptoms for 99% of those present at the WTCsite. One month later, more than half of our rescue workers were still reporting a daily cough and 2-4 years later,31% were still struggling with this symptom. With early diagnosis and treatment, the incidence rate of this symptomimproved compared to Day 1, but is still significantly higher than before 9/11/01 when only 3% of FDNY rescueworkers reported a daily cough. Other lower respiratory symptoms have followed a similar evolution over time.These persistent symptoms, coupled with objective proof of pulmonary function declines (see page 29), are whyFDNY WTC rescue workers should continue to participate in the long-term monitoring and treatment programsoffered by the WTC Program.5Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.LOWER RESPIRATORY SYMPTOMS100806040200Daily Cough Short of Breath WheezeChest Pain

F D N Y W T C R e s c u e W o r k e r s ( % )Pre-WTCWTC 9/11Post-WTC mo. 1Post-WTC yr. 1Post-WTC yrs. 2-428WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2 •MEDICAL QUESTIONNAIRE DATA6Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.Upper respiratory symptoms were the most common problems experiencedby FDNY rescue workers, but these symptoms, while persistent in many, havealso shown great improvement over time.6Upper respiratory symptoms (cough, nasal/sinus congestion/drip, sore/hoarse throat) have all followed a similarevolution during the four years following 9/11/01. On Day 1, more than half of our work force experienced all ofthe above symptoms. One year later, more than half of our rescue workers were still reporting upper respiratory symptoms and 2-4 years later, about 25% were still struggling with daily or frequent symptoms. Particulate matter analysishas shown a highly alkaline pH of WTC dust (like lye), which is extremely irritating to upper and lower airways.Day 1 9/11/01➤99% of FDNY rescue workerspresent were coughing➤80% had nasal congestion➤63% had sore/hoarse throatMonth 1 Post-WTC➤53% had a daily cough➤40% had frequent nasal congestion➤54% had frequent sore throatYear 1 Post-WTC➤46% had a daily cough➤25% had frequent nasal congestion➤46% had frequent sore throatYears 2-4 Post-WTC➤31% had a daily cough➤32% had frequent nasal congestion➤22% had frequent sore throatUPPER RESPIRATORY SYMPTOMS100806040200Daily Cough Frequent Nasal/SinusCongestion/DripFrequentSore/HoarseThroat

F D N Y W T C R e s c u e W o r k e r s ( % )Pre-WTCWTC 9/11Post-WTC mo. 1Post-WTC yr. 1Post-WTC yrs. 2-429SECTION 2 •SCIENTIFIC TEST RESULTSWorldTradeCenterHealthImpactsonFDNYRescueWorkersAlthough loss of lung function can be linked directly to arrival time, all exposuregroups experienced an unprecedented decline in lung function within thefirst 12 months following the WTC attacks.7Pre-WTC➤On average, FDNY rescue workerslose 31 milliliters (ml) of FEV1 eachyear (similar to US population averages)Within the First Year Post-WTC➤Members in Arrival Group I lost 388ml of FEV1 on average (more than12 times the average pre-WTCannual loss)➤Members in Arrival Group II lost372 ml of FEV1 on average (12times the average pre-WTC annualloss)➤Members in Arrival Group III lost357 ml of FEV1 on average (morethan 11 times the average pre-WTCannual loss)Since 1997, FDNY rescue workers have participated in a periodic medical evaluation (every 12 to 15months) to track health problems and determine work eligibility. One part of the evaluation is a pulmonaryfunction test (PFT), which measures forced vital capacity (FVC) and forced expiratory volume after 1 second(FEV1). FVC is the total amount of air one can forcibly breathe out. FEV1 is the amount of air one can forciblybreathe out in the first second. As we grow older, both FVC and FEV1 decline naturally at an average rate of20-30 ml per year. In this graph, we see a connection between arrival time at the WTC and pulmonary function loss, with members of Arrival Group I demonstrating a greater loss in FEV1 than members of ArrivalGroups II and III. Although the reduction in pulmonary function was greatest for those present during the collapse, FEV1 and FVC was decreased even in FDNY rescue workers arriving at later time periods. Similar findings were found for the FVC. Data obtained after September 2002 now are being analyzed and future FDNYWTC monitoring will allow us to determine if this decline plateaus, improves or continues. For those withsymptoms, we believe that treatment is the best way to ensure appropriate diagnoses and improvement.7Data analysis collected from PFTs by FDNY rescue workers Jan. 1996-Sept. 2002.

A d j u s t e d F E V 1 L o s s ( m l )Pre-WTCPost-WTC0-50-100-150-200-250-300-350-400-450-500PULMONARY FUNCTION LOSS:FIRST YEAR AFTER 09/11/2001BY ARRIVAL TIME EXPOSURE CATEGORY-388-372-357-31 -31 -31ArrivalGroup IArrivalGroup IIArrivalGroup IIIArrival Time Exposure CategoryGroup I = AM of 9/11/01;Group II = Next 36 hours (Day 1 PM & Day 2); Group III = After Day 230WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2 •SCIENTIFIC TEST RESULTS8Data analysis collected from PFTs by FDNY rescue workers Jan. 1996-Sept. 2002.When we break down our rescue workers into two groups, Firefighters had agreater average decline in pulmonary function than EMS members, but bothgroups still had greater average declines than pre-9/11/01.8The greater decline of FEV1 in Firefighters compared to EMS workers likely is due to the differing roles of eachjob in the rescue and recovery effort. Fire suppression and search activities kept the Firefighters closer to the burning debris and pulverized rubble. Although EMS workers have lost less lung function than the Firefighters, on average, they still showed a substantial decline in lung function, indicating WTC environmental site exposure. Thus, jobrelated tasks performed and perhaps proximity to the Ground Zero site played roles in the loss of lung function.Pre-WTC➤Entire FDNY rescue worker population loses 31 ml of FEV1 each year(near national average)First Year Post-WTC➤EMS employees lost 320 ml of FEV1on average (more than 10 times theaverage pre-WTC annual loss)➤Firefighters lost 384 ml of FEV1 onaverage (more than 12 times theaverage pre-WTC annual loss)➤Firefighters had 20% greater declinein FEV1 than EMS employeesPULMONARY FUNCTION LOSS: FIRST YEAR AFTER 9/11/2001BY WORK ASSIGNMENT (FIRE & EMS)0-50-100-150-200-250-300-350-400-450-500

A d j u s t e d F E V 1 L o s s ( m l )Pre-WTCPost-WTC-31 -31-320-384EMSFIRE31SECTION 2 •SCIENTIFIC TEST RESULTSWorldTradeCenterHealthImpactsonFDNYRescueWorkersThe Methacholine Challenge Test (MCT) is a specialized, objective test usedto confirm the diagnosis of asthma in symptomatic FDNY rescue workerswho have normal pulmonary function.91 Month Post-WTC,in a random sample:➤24.7% of highly exposed workers haveAirway Hyperreactivity (AHR)➤8% of moderately exposed➤3.6% of unexposed control group3 Month Post-WTC,in a random sample:➤23.8% of highly exposed workers haveAHR➤6.8% of moderately exposed➤3.6% of unexposed control group6 Month Post-WTC,in a random sample:➤27.6% of highly exposed workers haveAHR➤8.3% of moderately exposed➤3.6% of unexposed control groupMethacholine is a chemical that when inhaled at increasing doses in a controlled setting, identifies who is likelyto have asthmatic reactions. In susceptible subjects, this test can provoke an asthma attack (airway spasm). TheAmerican Thoracic Society defines significant airway hyperreactivity as a 20% drop in FEV1 at low-dose methacholine levels (<8mg methacholine). Airway hyperreactivity can be especially burdensome to Firefighters who, dueto the nature of their job, often are exposed to smoke, fumes or other irritants. Similar to our symptom and PFTdata, the methacholine challenge tests indicate a strong correlation with the earliest WTC arrival time. Before theWTC attacks, there was no history of asthma in our Firefighter work force. As shown in the above graph, these newonset cases in FDNY rescue workers were not just acute, temporary effects of exposure. Data we now are analyzing show long-term airway hyperreactivity persistence for 2 to 4 years among those initially affected.9Data analysis collected from PFTs by FDNY rescue workers Oct. 2001-April 2002.

P e r c e n t H y p e r r e a c t i v eArrival Group IArrival Group IIUnexposed Group1 Month 3 Month 6 Month Control302520151050METHACHOLINE CHALLENGE TESTINGHYPERREACTIVE SUBJECTS (PC20 <8)n=19/77n=19/80n=2/25n=3/44n=3/36n=1/28n=21/7632WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 2 •DISEASE SURVEILLANCE10Data analysis collected from medical charts of FDNY rescue workers Jan. 1985-Sept. 2006.OTHER RESPIRATORY DISEASES EMERGING AFTER 9/11/01: The incidence ofsarcoidosis or WTC sarcoid-like granulomatous pulmonary disease (SLGPD)increased markedly in the first year post-WTC.10Sarcoidosis is an inflammatory disease producing tiny lumps of cells (granulomas) in multiple organs, mainly thelungs, lymph nodes and skin, all of which are entry points for occupational and environmental agents. The causeis unclear, but sarcoidosis is associated with exposures to organic and chemical dusts, metals, silica and wood dustor smoke. Compared to population values, FDNY-BHS showed increased incidence of sarcoidosis in FDNYFirefighters during the 15 years pre-WTC, presumably due to smoke exposure. After 9/11/01, the number of newFDNY sarcoidosis cases increased dramatically, especially in the first year post-WTC. In contrast to pre-9/11, mostnew cases are symptomatic (69%) with shortness of breath, cough and other asthma-like symptoms. Because ourcases primarily involve the lung, it may be more accurate to classify them as WTC “sarcoid-like” granulomatouspulmonary disease (SLGPD). Other rare pulmonary diseases in FDNY rescue workers have included 2 witheosinophilic pneumonitis (occurring in 2002 and cured with early diagnosis and treatment) and 4 with pulmonaryfibrosis (1 fatality in 2004 and 1 who may need a lung transplant).15 Years Pre-WTC➤0 to 5 FDNY rescue workers contractsarcoidosis annually, an averageincidence rate of 13/100,000.Most were asymptomatic9/11/01-9/11/02➤13 new cases develop in FDNY rescue workers, an 86/100,000 annualincidence rate (or more than a 6-foldincrease from pre-WTC levels)9/11/02-9/11/06➤13 new cases of sarcoidosis developin the next four years, an averageannual incidence rate of22/100,000Asthma➤69% of those diagnosed with sarcoidosis since 9/11/01 had newonset asthmaAirway Hyperreactivity (AHR)➤8 of 21 (38%) of sarcoidosis patientswho take a challenge test have AHR14121086420

N u m b e r o f P a t i e n t s“SARCOID-LIKE” GRANULOMATOUS PNEUMONITISFDNY: PRE- & POST-WTC

1985 1987 1989 1991 1993 1995 1997 1999 9/11/01-02 9/11/03-04 9/11/05-06SECTION 3MENTAL HEALTHASSESSMENTMental Health Questionnaire Data◆FDNY WTC Survivors Closely Linked to Those Lost on 9/11/01➤WTC-Related Health Concerns by Arrival Time➤WTC-Related Concerns About Early Mortality by Arrival Time➤Change in Sleep-Related Issues After WTC➤Change in Mood After WTC➤Feelings of Distance and Detachment After WTC➤Reliving and Remembering the WTC Experience➤Change in Exercise Program After WTC➤34FDNY members and trades personnel work at Ground Zero.WorldTradeCenterHealthImpactsonFDNYRescueWorkers35WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 3MENTAL HEALTH ASSESSMENTFor more than 25 years, the FDNY Counseling ServiceUnit (FDNY-CSU) has been meeting the needs of theFDNY community. Prior to 9/11/01, it provided coun-seling for family issues, personal stress or when anFDNY member died. In response to the World Trade Centerattacks and the tragic loss of 343 members of our FDNY family from more than 60 firehouses and 2 EMS stations, wequickly adapted and expanded our programs, trained personnel, visited every firehouse and EMS station and added counseling sites to provide emergent and extensive mental healthservices to members and their families, including the familiesof deceased rescue workers. The FDNY-CSU played a principal role in the evaluation, treatment and monitoring of the psychological response to the 9/11 attacks. Because our CSUhad significant experience and understanding of our members,programs were developed to meet specific needs. Now, in thesixth year after this tragedy, our dedicated staff continues itsmission of caring for the mental health of our members (bothactive and retired) and their families.In addition, mental health questionnaires from the FDNY WTCProgram helped to further identify mental health concerns andtrends. One of the goals of these questionnaires was to identifythe scope and severity of the psychological and physical damageresulting from the WTC terrorist attacks in an effort to providefocused interventions/treatments and monitor response rates. Theinformation collected is used not only to improve the quality ofcare provided by the FDNY-CSU and FDNY-BHS, but also toincrease our general understanding of mental health responsesafter major disasters. This is a critical issue for our members asthey are always among the first to respond to such disasters.Our initial questionnaire asked FDNY rescue workers aboutarrival time at the WTC and total time spent at WTC sites in themonths that followed. The mental health portion asked aboutemotional well-being through questions aimed at identifyingsymptoms and behavioral patterns related to stress, anxiety anddepression. It examined changes in the ability to function, bothin their personal and work lives, which may have occurred dueto psychological problems resulting from 9/11, such as anger,irritability and anxiety; memory and concentration problems;changes in eating, sleeping and exercise patterns; and increases in alcohol and tobacco usage. As we had not rigorously collected mental health information pre-9/11, we present theseself-reported data without comparison.The mental health questionnaire also collected data on thenumber of people utilizing our counseling services and the typesof counseling used. It should be noted that the members takingtheir medicals and responding to these questionnaires were, forthe most part, on full-duty, working in the field, but also included our light-duty members and affected retirees.Our findings after 9/11 show the persistent emotionalimpact left by this tragedy, with the greatest effects realized inFDNY rescue workers who either were at the WTC site during thecollapse or lost loved ones on 9/11.Section 3 of this report will discuss the psychological effects of working at the WTC site by examining self-reported data from our medical questionnaires.36WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 3 •MENTAL HEALTH ASSESSMENT1Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Oct. 2002.The majority of FDNY members reported close ties to thoselost at the WTC site.1An overwhelming 98% of FDNY rescue workers knew at least one person who died at the WTC and many knewmore than one person. In addition to being members of the FDNY extended family, the 343 rescue workers we lostthat tragic day held multiple, diverse roles as spouses, fiancés, significant others, fathers, sons, brothers, friends andcoworkers. The close bonds formed between those members who sacrificed their lives and those who survived helpto explain the extent of our members’ suffering in the aftermath of 9/11. Despite the loss of their loved ones, ourmembers dedicated themselves to continuing the search for the missing. Each anniversary, memories and unexpected reports of new identifications can serve to rekindle these emotions.➤98% of FDNY rescue workers lostsomeone they knew on 9/11/01➤68% lost FDNY close friends➤52% lost FDNY acquaintances➤7% lost FDNY relatives➤23% lost non-FDNY relatives andclose friendsFDNY WTC SURVIVORS CLOSELY LINKED TO THOSE LOST ON 9/11/01100806040200

F D N Y W T C R e s c u e W o r k e r s %Knew someone FDNY CloseFriendsFDNYAcquaintancesFDNYRelativesNon-FDNYRelatives &Friends98685272337SECTION 3 •MENTAL HEALTH ASSESSMENTWorldTradeCenterHealthImpactsonFDNYRescueWorkersEarly responders expressed the greatest healthconcerns after working at the WTC site.2Year 1 Post-WTC➤All FDNY Rescue Workers93% had WTC-related health concerns➤Arrival Group I95% had health concerns➤Arrival Group II94% had health concerns➤Arrival Group III85% had health concernsWTC-related health concerns are seen in all response groups, regardless ofarrival time. Clearly, those groups arriving on Day 1 or Day 2 had significant concerns about their health when faced with air quality issues. These groups also personally witnessed the largest amount of injury, death and destruction.2Data analysis collected from questionnaires completed byFDNY rescue workers Oct. 2001-Oct. 2002.FDNYAny Arrival TimeArrival Group I Arrival Group II Arrival Group III100806040200WTC-RELATED HEALTH CONCERNSBY ARRIVAL TIMEArrival Time Exposure CategoryGroup I = AM of 9/11/01; Group II = Next 36 hours (Day 1 PM & Day 2);Group III = After Day 293959485

F D N Y W T C R e s c u e W o r k e r s ( % )Concerns about early mortality among FDNY rescueworkers are strongly correlated to arrival time at WTC.3WTC-RELATED CONCERNS ABOUT EARLYMORTALITY BY ARRIVAL TIME100806040200

R e s c u e W o r k e r s ( % )FDNYAny Arrival TimeArrival Group I Arrival Group IIArrival Group IIIArrival Time Exposure CategoryGroup I = AM of 9/11/01; Group II = Next 36 hours (Day 1 PM & Day 2);Group III = After Day 222312214In the mental health questionnaire, 22% of FDNY rescue workers answered thatthey were “feeling as if (their) future will be cut short” by WTC exposures and relatedillnesses. These results are not surprising, as those members present before and during the collapse of the towers personally experienced the prospect of death, witnessedthe sudden loss of coworkers and inhaled the most dust. We know that regardless ofarrival time, all FDNY rescue workers suffered varying inhalation exposures and werein proximity to those who perished. Concerns about early mortality among our FDNYrescue workers are to be expected. As can be seen in the next group of figures, theseexposures and concerns translate into high rates for symptoms that are common ingrief reactions, post-traumatic stress disorder (PTSD) and depression.Years 2-4 Post-WTC➤All FDNY Rescue Workers22% had early mortality concerns➤Arrival Group I31% had early mortality concerns➤Arrival Group II22% had early mortality concerns➤Arrival Group III14% had early mortality concerns3Data analysis collected from questionnaires completed by FDNY rescue workersOct. 2002-Aug. 2005.38WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 3 •MENTAL HEALTH ASSESSMENTFDNY rescue workers self-reported numerous sleep issues in the first fouryears after working at the WTC site.4Sleep disturbances were prominent in the first year after 9/11/01 and persisted in years 2 through 4. Thiscould be related to changes in mood and anxiety after the WTC attacks, nightmares, the amount of time spentworking at the WTC or changes in exercise patterns. Our results indicate that although healing is occurring, thesesymptoms persist.4Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.

F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC yr. 1Post-WTC yrs. 2-4Any SleepRelated IssueDifficultySleepingDifficultyGetting GoodNight’s SleepNightmares DifficultyGettingOut of Bed100806040200CHANGE IN SLEEP-RELATED ISSUES AFTER WTC615833 34463927221413Year 1 Post-WTC➤61% of all FDNY WTC rescue workers reported having sleep-relatedproblems➤33% had trouble sleeping➤46% had trouble getting a goodnight’s sleep➤27% had nightmares➤14% had difficulty getting out of bedYears 2-4 Post-WTC➤58% had sleep-related problems➤34% had difficulty sleeping➤39% had trouble getting a goodnight’s sleep➤22% had nightmares➤13% had difficulty getting out of bed39SECTION 3 •MENTAL HEALTH ASSESSMENTWorldTradeCenterHealthImpactsonFDNYRescueWorkersMood changes that occurred after working at the WTC have endured formore than 4 years.5Self-reported persistent changes in concentration, irritability and anger are widespread, with more thanhalf of our WTC-exposed work force exhibiting at least one of these symptoms. Again, this shows long-termpsychological effects from the WTC attacks and that continued attention to mental health is needed.Continued usage of counseling services at CSU indicates that this need remains strong 4 years later. (For alist of CSU locations and phone numbers, please see page 62.)

F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC yr. 1Post-WTC yrs. 2-4Any MoodIssueDifficultyConcentratingUnusuallyIrritableUnusualAngerUnusuallyAnxious100806040200CHANGE IN MOOD AFTER WTC585332 3235 3523322729Year 1 Post-WTC➤58% of all FDNY WTC rescueworkers report a change in mood➤32% had difficulty concentrating➤35% were unusually irritable➤23% had unusual anger➤32% were unusually anxiousYears 2-4 Post-WTC➤53% report a change in mood➤32% had difficulty concentrating➤35% were unusually irritable➤27% had unusual anger➤29% were unusually anxious5Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.40WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 3 •MENTAL HEALTH ASSESSMENTMany WTC rescue workers continue to feel distant anddetached after 9/11/01.6Many members showed persistent behavioral changes and complex emotional reactions consistent with astress-induced response to the disaster. Feeling numb, distant or detached are frequent findings in those suffering from PTSD, a psychiatric disorder that occurs after exposure to a terrifying event in which serious physical harmoccurred or was threatened (as in the case of the WTC attacks). PTSD may occur immediately or at a later timeand may persist. Effective treatment strategies involving social support, counseling and/or medications are available at FDNY-CSU. It is unclear why some people are more prone to developing PTSD than others, but theprocess likely involves complex genetic, physical and social factors that are unique to each individual.6Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.

F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC yr. 1Post-WTC yrs. 2-4AnyPsychologicalIssueFeelNumbFeel DistantfromFamily/FriendsFeel Distantfrom OthersFeel DetachedfromSurroundings100806040200FEELINGS OF DISTANCE AND DETACHMENT AFTER WTC60531910202021221713Year 1 Post-WTC➤60% of FDNY rescue workers reportpsychological issues (including reexperience issues)➤19% felt numb➤20% felt distant from friends or family➤21% felt distant from others➤17% felt detached fromsurroundingsYears 2-4 Post-WTC➤53% report psychological issues(including re-experience issues)➤10% felt numb➤20% felt distant from friendsor family➤22% felt distant from others➤13% felt detached fromsurroundings41SECTION 3 •MENTAL HEALTH ASSESSMENTWorldTradeCenterHealthImpactsonFDNYRescueWorkersYear 1 Post-WTC➤60% of FDNY rescue workers reportpsychological issues (includingdetachment issues)➤29% had flashbacks of WTC➤15% avoided things or people associated with WTC➤9% had difficulty remembering theWTCYears 2-4 Post-WTC➤53% report psychological issues(including detachment issues)➤29% had flashbacks of WTC➤15% avoided things or people associated with WTC➤15% had difficulty remembering theWTC➤11% had physical reactions to WTCmemories➤20% had guilt feelings about WTC7Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.Nearly 30% of FDNY rescue workers continue to have flashbacksfrom the WTC experience.7With nearly one in three FDNY WTC rescue workers still having flashbacks, clearly, there are still many residual emotional reactions from that day. This, too, may be a sign of PTSD. Complicating matters, the stressful situations encountered in the day-to-day rescue work that our members perform can trigger or exacerbate WTCmemories and stress reactions long after 9/11/01. Symptoms related to memories of 9/11 and flashbacks fromthe event continue to demonstrate persistent WTC-related grief reactions, PTSD and depression in our members.Guilt can take different forms; this includes guilt for those who were not present during the collapse and survivorguilt. In their struggle to hold on to those they lost, our members are clearly retaining painful memories. They arelearning how best to identify and manage the residual stress associated with the WTC memories, while holdingon to the need to “never forget.”

F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC yr. 1Post-WTC yrs. 2-4Any PsychologicalIssueFlashbackMemories ofWTCAvoiding WTCThings/PeopleDifficultyRememberingWTCPhysicalReaction toWTCMemoriesGuiltFeelingsabout WTC100806040200RELIVING AND REMEMBERING THE WTC EXPERIENCE605329 2915 15915112042WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 3 •MENTAL HEALTH ASSESSMENT8Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.In the first year after 9/11/01, the majority of our members exercised less thanthey did before the WTC attacks. However, these trends are reversing for avariety of reasons.8Given the physical demands of the job, we always expect to find most FDNY rescue workers engaged inan active lifestyle. As our members are aware, exercise provides an excellent outlet for stress reduction.However, in the first year following the WTC attacks, exercise routines were decreased in more than half ofthe FDNY rescue workers. This may have complicated the ability to handle stress. The increased activity levelbetween year 1 and years 2-4 reflects increased time available for exercise and, hopefully, the improvingstate of health (physical and mental) of our rescue workers.Year 1 Post-WTC➤66% of FDNY rescue workersreported a change in exercise program post-WTC➤37% exercised less due to lack oftime➤23% exercised less because theydid not feel like it➤5% exercised moreYears 2-4 Post-WTC➤46% reported no change in exercise compared to pre-WTC routine➤13% exercised less due to lack oftime➤15% exercised less because theydid not feel like it➤18% exercised more F D N Y W T C R e s c u e W o r k e r s ( % )Post-WTC yr. 1Post-WTC yrs. 2-4Change in routine Decreased dueto lack of timeDecreasedbecause do notfeel like itIncreased1009080706050403020100CHANGE IN EXERCISE PROGRAM AFTER WTC664637132315518SECTION 4FDNY RETIREMENTANDDISABILITY DATAFDNY Retirements and Years of Service➤Disability Pensions Received◆Number of Pulmonary Cases Under the Lung Bill➤Number of Permanent Psychological Impairment Cases➤Number of Cardiac Cases Under the Heart Bill➤Number of Cancer Cases➤NYCERS EMS “3/4” Disability Pension Applications Approved➤44343 flag-bearing FDNY members proudly march up 5th Avenue, passing theMetropolitan Museum of Art in the March 17, 2002, St. Patrick’s Day Parade.WorldTradeCenterHealthImpactsonFDNYRescueWorkers45WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 4The traumatic events of 9/11 affected both thephysical and mental health of our members. Thisresulted in an unprecedented number of Firefighterretirements in the two years following 9/11, as wellas an increased number of disability pensionsgranted by the FDNY.FDNY RETIREMENTANDDISABILITY DATAIn years pre-9/11 (9/11/99 to 9/10/01), there wasan average of 544 annual Firefighter retirements. Inthe first two years post-WTC, 1216 and 1201Firefighters retired annually. In the next three years,the average number of retirees returned to pre-WTC values and the work force now is younger with fewer members having 20 or more years of service. One third of thework force retired between 9/11/01 and 9/10/06. Thenumber of EMS retirements has not increased after9/11/01.Exposed retirees may represent the most severelyaffected of the more than 1500 Firefighters diagnosedwith respiratory disease. From 2002-2006, 728 members qualified for permanent disability benefits under the“Lung Bill.” Many of those who retired were our seniorand most respected members. These figures also highlight the need to continue our outreach to FDNY retiredrescue workers to make certain they continue in our medical monitoring and treatment programs. Only with earlydiagnosis and treatment can we hope to reduce thepotential long-term impact of this exposure in later retirement years.In the 2 years following 9/11/01, there was an unprecedentednumber of FDNY Firefighter retirements.FDNY Retirements and Years of ServiceDATE EMS FIRE FIRE (>20 YRS.) FIRE (>20 YRS.)Percent9/11/99 to 9/10/00 250 534 356 679/11/00 to 9/10/01 269 554 352 649/11/01 to 9/10/02 157 1216 755 629/11/02 to 9/10/03 199 1201 866 729/11/03 to 9/10/04 139 573 318 559/11/04 to 9/10/05 136 603 265 449/11/05 to 9/10/06 108 621 315 5146WorldTradeCenterHealthImpactsonFDNYRescueWorkers1Data analysis collected from FDNY Fire pension records.The persistent increase in disability pensions granted under theLung Bill reflects WTC exposure and related disease.1Due to the nature of the profession, Firefighters inevitably are exposed to smoke and potentially at risk forsevere respiratory problems. Long before the WTC attacks, Firefighters have had to turn to the FDNY disabilitypension system when lung problems interfered with occupational demands. The provisions of the Lung Bill recognize the hazards of firefighting, with its recurrent exposures despite protective gear and SCBA. This system provides disability pensions only after a rigorous, objective evaluation of pulmonary function. The dramatic increasenoted above after 2001 is strongly tied to the WTC-related respiratory symptoms and loss of pulmonary functiondescribed previously. From 2002 to 2006, 728 members qualified for permanent disability benefits under theLung Bill.NUMBER OF PULMONARY CASES RECEIVING FDNYDISABILITY PENSION (“3/4”) UNDER THE LUNG BILL

# o f C a s e s25020015010050019992000 2001 2002 2003 2004 2005Year4558441352006127Pre-WTCPost-WTC153181132SECTION 4 • FDNY RETIREMENT AND DISABILITY DATAPre-WTC➤An average of 49 FDNY Firefightersand Fire Officers collect disabilitypensions for lung problems annuallyPost-WTC➤An average of 146 FDNYFirefighters and Fire Officers collectdisability pensions for lung problemsannually47SECTION 4 • FDNY RETIREMENT AND DISABILITY DATAWorldTradeCenterHealthImpactsonFDNYRescueWorkersPre-WTC➤No cases of permanent psychologicalimpairment received disability pensionPost-WTC➤An average of 15 annual permanentpsychological impairment casesreceive disability pension2Data analysis collected from FDNY Fire pension records.In this resilient population, certain members developed permanentpsychological impairments and were granted service-connecteddisability pensions for these problems.2With rare exceptions, FDNY did not provide disability pensions for stress-related cases until after theevents of 9/11/01. This began in acknowledgement of the harrowing events experienced by FDNY-WTCFirefighters and Fire Officers, including the loss of friends and coworkers and personally witnessing vastamounts of death and destruction. From 2002 to 2006, 75 members qualified for permanent disabilitybenefits due to psychological impairment.NUMBER OF PERMANENT PSYCHOLOGICALIMPAIRMENT CASES RECEIVING DISABILITY PENSION (“3/4”)

# o f C a s e s25201510501999 2000 2001 2002 2003 2004 2005 2006Year0002016Pre-WTCPost-WTC1620348WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 4 • FDNY RETIREMENT AND DISABILITY DATAFollowing the WTC attacks, the average number of cardiac cases receivingFDNY disability pension under the Heart Bill has remained unchanged, butthere were spikes in years 2002 and 2006that we are studying more closely.3Under the provisions of the Heart Bill, FDNY disability pensions are granted only for coronary artery disease.Members with other cardiac illness, such as cardiomyopathy and cardiac rhythm problems, currently do not fallunder the provisions of the Heart Bill. WTC monitoring will continue to evaluate members to look for patterns ofcardiac health after this exposure. At periodic medical evaluations, FDNY-BHS continues to stress efforts to modify cardiac risk factors (obesity, sedentary lifestyles, elevated cholesterol levels, smoking, etc.). In 2002, there wasa spike in numbers, with a return to pre-WTC levels in 2003-2004. Members with known cardiac problems mayhave deferred retirement for one year to help with the rescue and recovery effort post-WTC. Numbers decreasedin 2005 and then increased in 2006. We continue to study this issue.3Data analysis collected from FDNY Fire pension records.NUMBER OF CARDIAC CASES RECEIVING FDNY DISABILITYPENSION (“3/4”) UNDER THE HEART BILL

# o f C a s e s5040302010019992000 2001 2002 2003 2004 2005 2006Year2323291235Pre-WTCPost-WTC222039Pre-WTC➤An average of 25 FDNY Firefightersand Fire Officers collect disabilitypensions for cardiac problemsannuallyPost-WTC➤An average of 26 FDNY Firefightersand Fire Officers collect disabilitypensions for cardiac problemsannually49WorldTradeCenterHealthImpactsonFDNYRescueWorkersPre-WTC➤An average of 15 FDNY Firefightersand Fire Officers collect disabilitypensions due to cancer annuallyPost-WTC➤An average of 16 FDNY Firefightersand Fire Officers collect disabilitypensions due to cancer annually➤In 2006, there were an additional15 cases due to newly eligibleretirees under the WTC BillThe Cancer Bill (1994) is a presumptive bill that was enacted inrecognition of Firefighters’ daily occupational exposures to known carcinogens. The WTC Bill (June 2005) is alsoa presumptive bill that was enacted inrecognition of WTC exposures andencompasses many ailments, including disabilities related to the lungs,upper respiratory system and cancer.The Cancer Bill is available only toactive members who have a disablingcancer. The WTC Bill is available toany active or retired FDNY memberwho was on active duty during the rescue and recovery effort and thendeveloped a covered disabling condition. In 2006, Firefighters first becameeligible for the WTC Bill.The number of members retiringdue to cancer has been high for awork force this size, both pre- andpost-9/11/01, reflecting the exposuresto smoke and toxins consistently experienced by our members. In 2006, there was a marked increase in the number of pensions granted due to cancer;however, this is the first year of broadened eligibility due to the WTC Bill and a significant portion of the increaseappears to be due to previously ineligible retirees who now are eligible. Of the 15 WTC Bill cancer pensions granted in 2006, more than two-thirds were awarded to retired members seeking reclassification of their retirement status. Before 2006, these reclassifications were not possible and cancers among retirees were not tracked. Veryrecently, these data have become available to us (June 2007) and it is too soon to comment on patterns or typesof cancers. We are in the process of intensive investigation and will continue to obtain information from active members and retirees before finalizing our statistical analyses. A full report will be forthcoming in the near future.Cancer is a late-emerging disease that may take years or even decades to manifest in an individual, highlighting the need for FDNY rescue workers to continue in this monitoring program. This is especially true of our retiredmembers, who--until now--we have had no way to monitor following prior exposures. The federal funding provided for the FDNY WTC Program has created the opportunity for retired members to continue their monitoring forlate-emerging diseases. This is the only way we can determine if cancer post-WTC has increased and the only wayto provide early diagnoses, which can improve outcomes. Also, for those few who smoke, we highly recommendparticipation in our free WTC Tobacco Cessation program to reduce future additional carcinogenic exposures. Inprior environmental/occupational disasters, the highest cancer rates have been in smokers.SECTION 4 • FDNY RETIREMENT AND DISABILITY DATA4Data analysis collected from FDNY Fire pension records.FDNY-BHS is closely monitoring late onset diseases, such as cancers, to lookfor emerging patterns post-WTC.4NUMBER OF CANCER CASES RECEIVINGFDNY DISABILITY PENSION (“3/4”)

# o f C a s e s353025201510501999 2000 2001 2002 2003 2004 2005 200615161510191920WTC Bill--RetireesCancer Bill Post-9/11Cancer Bill Pre-9/111215WTCDisability Bill--newly eligibleretirees50WorldTradeCenterHealthImpactsonFDNYRescueWorkersEMS personnel collect disability pensions through New York City Employees’ Retirement System (NYCERS).Like the FDNY system for Firefighters, disability pensions for EMS personnel are approved only after rigorous,objective health evaluations have been reviewed by an independent board. The numbers in the above graphinclude disability pensions collected for respiratory ailments, permanent psychological impairment and disabling cancers, as well as pensions collected under the Heart Bill and, beginning in 2006, the WTC Bill. Priorto 2006, disability pensions from WTC-related injuries and illnesses were not distinguished from non-WTCcauses. Between 1/1/06 and 7/30/07, 9 EMS personnel were granted pensions under the WTC Bill. NYCERScould not provide us with diagnoses due to confidentiality issues, but of these 9 cases, FDNY-BHS had diagnosed 4 with asthma, 2 with sarcoidosis, 1 with cancer, 1 with PTSD and 1 with both asthma and PTSD.NYCERS EMS “3/4” DISABILITY PENSIONAPPLICATIONS APPROVED

# o f C a s e s353025201510502000 2001 2002 2003 2004 2005 2006Year21192424Pre-9/11Post-9/11292324Pre-WTC➤An average of 20 EMS personnelcollect “3/4” disability pensionsannuallyPost-WTC➤An average of 25 EMS personnelcollect “3/4” disability pensionsannually. 9 EMS personnel collect“3/4” disability pensions under theWTC BillSECTION 4 • NYCERS EMS RETIREMENT AND DISABILITY DATASECTION 5THE FDNY-WORLD TRADE CENTERMEDICAL MONITORINGANDTREATMENT PROGRAMPOST-9/11/01Number of Monitoring Exams Conducted➤Annual Number of Patients in the FDNY-WTC Medical Treatment Program➤Tobacco Cessation Success Rates➤CSU Provides Counseling and Treatment➤Annual Number of Patients in the FDNY-CSU WTC Mental Health Treatment Program➤52SECTION 5More than five years after the attack, the FireDepartment’s WTC Program continues itscommitment to providing our members withthe best monitoring and treatment programspossible.WorldTradeCenterHealthImpactsonFDNYRescueWorkersMonitoring Program Total Enrollment: 14,319 (10/01 to 06/30/07)1To date, 14,319 members participate in the FDNY WTC Program. WTC medical monitoring exams continue tobe provided every 12-18 months to every active member (Fire and EMS) who served at any WTC site. This examis part of the regular periodic company medical. As of April 30, 2007, 10,415 incumbents had received an initial monitoring exam and 8687 had received at least one follow-up monitoring exam (83% retention rate). Visit 3follow-up monitoring exams began October 5, 2006, and the number of members receiving these exams will rise.For the first time in FDNY history, we have included retirees in this post-exposure program. In the first six monthsafter 9/11/01, more than 1100 retirees participated in the WTC Monitoring and Treatment Program. As of April30, 2007, this has expanded to include 3904 retirees who have received an initial monitoring exam and 1898who have received at least one follow-up monitoring exam (49% retention rate). To improve our ability to schedule exams for retirees, we will be starting an intensive phone outreach campaign shortly after the sixth-year anniversary of the WTC attacks in September 2007. Participation in the monitoring program is a requirement to obtainfree treatment and medication.NUMBER OF MONITORING EXAMS CONDUCTED16,00014,00012,00010,00080006000400020000Visit 1 and 2 Base line Visit 2 Follow-Up Visit 3 Follow-Up*FDNY-WORLD TRADE CENTER MEDICAL MONITORING EXAMS POST-9/11/01THIS PROGRAM INCLUDES FIRE AND EMS (ACTIVE AND RETIRED).TotalFirefighter ActiveFirefighter RetiredEMS ActiveEMS Retired1Data analysis, FDNY rescue workers Oct. 2001-June 2007.* Visit 3 examsfor retirees tostart Fall 2007.➤14,319 members have participated in FDNY-WTC monitoring53WorldTradeCenterHealthImpactsonFDNYRescueWorkersImmediately after 9/11/01, FDNY-BHS started a treatment program for WTC-related conditions. We were the firstto describe the WTC Cough Syndrome and document that treatment was effective (New England Journal of Medicine,2002). Between 9/12/01 and 6/30/07, we have seen 6465 patients at a total of 40,313 visits. In December 2006,FDNY-BHS expanded monitoring and treatment services for WTC-related physical and respiratory illnesses. Our primary care doctors have received specialized training and are available for initial treatment interventions. Referrals thencan be made to our two in-house lung specialists with 75 appointments available weekly. More appointments can beadded as needed. FDNY rescue workers at high exposure risk are offered chest CT imaging.Recognizing that treatment has been effective, but costly for members and their unions, NIOSH recently has funded an FDNY no-cost prescription medication program for WTC-related conditions (respiratory, sinus, GERD, mentalhealth). Since medications have been provided, there has been an increase in treatment visits. All FDNY WTC rescueworkers (Fire and EMS, active and retired) who were at the WTC during the collapse/rescue/recovery effort (9/11/01to 7/02) and have received a WTC medical monitoring exam at FDNY-BHS (anytime since 8/12/05), qualify for thisprogram. Those meeting the above eligibility requirements already should have received instructions and a specialFDNY WTC Program prescription card. Eligibility and contact information can be verified or an updated WTC medical monitoring exam can be scheduled for you. (See page 62 for further information.)SECTION 5 •FDNY-WORLD TRADE CENTER MEDICAL TREATMENT POST-9/11/01THIS PROGRAM INCLUDES FIRE AND EMS (ACTIVE AND RETIRED).ANNUAL NUMBER OF PATIENTS IN THE FDNY-WTCMEDICAL TREATMENT PROGRAM3000250020001500100050009/12/01 to06/30/027/1/02 to06/30/037/1/03 to06/30/047/1/04 to06/30/057/1/05 to06/30/067/1/06 to06/30/07Note: The above chart counts each patient only once in any given time range.➤6465 members have participatedin the FDNY-WTC treatment program for “WTC cough”54WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 5 • THE FDNY-WORLD TRADE CENTER MEDICAL MONITORING ANDTREATMENT PROGRAM POST-9/11/01Our studies have shown no link between current FDNY-WTC health findings and tobacco use. Because it iswell-known that tobacco use results in an increased risk for the development of respiratory disease and cancer inasbestos workers, we felt it was prudent to offer our members a tobacco cessation program. “Tobacco Free withFDNY” is a free tobacco cessation program that provides counseling, nicotine replacement medication and othermedications when necessary. More than 600 members (active, retirees and family members) have participated inour program. We are proud to have some of the highest reported tobacco cessation rates in the nation. In a studyconducted on our first participants, 47%, 36% and 33% had stopped smoking for 3, 6 and 12 months, respectively. This program continues every Wednesday, alternating between FDNY-BHS and Fort Totten. (See page 62for contact information.)Tobacco Cessation Rates➤47% of participants remained tobacco-free continuously for 3 months➤36% remained tobacco-free for 6months➤33% remained tobacco-free for 12monthsTOBACCO CESSATION SUCCESS RATES

P e r c e n t10090807060504030201003 months6 months12 months364733FDNY Tobacco Cessation ProgramDue to WTC-related respiratory illness and health concerns about cancerdevelopment, FDNY-BHS and FDNY-CSU started a free tobacco cessationprogram. Only 15% of our rescue workers use tobacco, but post-WTC stresscaused tobacco use to increase.“I came to the program having failed in numerousattempts to quit smoking. I was a smoker many yearsbefore, but picked up the ‘habit’ on September 11,2001. I never thought I’d become a full-time smoker as I never was one, but I guess the stress on thatday and the weeks and months that followed gaveme the excuse to keep smoking. Smoking definitelyeased the anxiety, which I always found counterintuitive with nicotine being a stimulant, but I suppose bythen I was addicted and more of my anxiety wascoming from the withdrawal than from anything that9/11 may have been contributing. I didn’t know itthen, but certainly know it now.Thanks for helping to save my life.”Capt. Robert E. HigginsTobacco Cessation Program55SECTION 5 • THE FDNY-WORLD TRADE CENTER MEDICAL MONITORING ANDTREATMENT PROGRAM POST-9/11/01WorldTradeCenterHealthImpactsonFDNYRescueWorkersPrior to 9/11/01, the FDNY Counseling ServicesUnit (FDNY-CSU) consisted of 11 full-time coun-selors working at one location in Manhattan. Thisunit was responsible for counseling FDNY members on abroad range of issues, both personal and professional.FDNY-CSU also ran an outpatient substance abuse program and provided counseling during times of disaster,such as line-of-duty deaths (3 to 5 per year on average).When catastrophe struck on 9/11/01, we realizedthat rapid expansion was needed to provide assistanceto our members. Recognizing early on the need for anextensive network of counseling and support groups, weacted quickly by tapping into counselors from two partner organizations--the International Association of FireFighters (IAFF) and the National Fallen FirefightersFoundation (NFFF), who rushed to provide assistance.We established Debriefing Groups at the WTC site fromSeptember 11, 2001, through June 8, 2002, to supportand provide crisis counseling to those workers involvedin the recovery effort. Post-WTC Trauma Groups wereavailable, as needed, at FDNY-CSU locations. Weoffered extended counseling services at additionalFDNY-CSU offices located in members’ communities.Two weeks following 9/11, FDNY-CSU units wereestablished in Staten Island, Fort Totten (Queens) andlater in Suffolk and Orange Counties. For a list of CSUsite addresses and phone numbers, please refer to thepanel on the right. These sites provided individual counseling and support groups for FDNY workers and families, as well as the family members of the deceased. Wealso provided services conducted by FDNY-CSU clinicians, trained outside mental health counselors andtrained peer counselors at FDNY work locations. Thefirehouses and EMS stations that were visited initially andprovided with on-site counseling were those that had lostone or more of their members at the WTC site. Asstaffing increased, every work location was visited andcounseling was offered.The volume of members who sought help through theFDNY-CSU increased dramatically. From 9/11/01through 2006, the utilization patterns for the FDNY-CSUshowed a four- to five-fold increase. Pre-9/11, FDNYCSU saw, on average, 50 new clients a month at its onesite, compared with more than 260 per month post9/11. To date, this pattern of activity has continued.Annually, CSU continues to see nearly 3000 FDNYrescue workers (Fire and EMS, active and retired) andaffected family members. New programs introduced byFDNY-CSU recognize the changing and varied needs ofour members. These include the “Stay Connected” program for members and their families during transition toretirement.FDNY-CSU provides services for families of thedeceased, including various specialized bereavementgroups for spouses, fiancées, significant others, siblings,parents and children. CSU worked with BHS to establishtwo newsletters:The Link, which addressed the specificneeds of FDNY families who lost a loved one, andHealth Connections, which focused on all of our FDNYmembers. Conferences and workshops were provided tofocus on stress management, PTSD, chemical dependency, grief and bereavement and personal relationshipcommunication. Families of the deceased were offeredan array of services, including a Big Brother/Big Sisterprogram sponsored jointly by CSU and the UFA/UFOA.CSU Provides Counseling and TreatmentFDNY-CSU LocationsManhattan Counseling Unit251 Lafayette Street, 3rd Fl, NYC 10012(212) 570-1693 (24-Hour Line)Staten Island Counseling Unit1688 Victory BoulevardStaten Island, NY 10314(718) 815-4111Fort Totten Counseling UnitFort Totten Building 413ABayside, NY 11364(718) 352-2140Brentwood Counseling UnitLiberty Project CenterSuffolk County Community CollegeCrooked Hill Road,Brentwood, NY 11717(631) 851-6888Orange County Counseling Unit2279 Goshen TurnpikeMiddletown, NY 10941(845) 695-1029Substance Abuse Day-TreatmentProgram594 Broadway, Suite 500(212) 925-6671FDNY Headquarters9 MetroTech CenterBrooklyn, NY 11201-3857(718) 999-1858(718) 999-0088 (fax)Medical Monitoring ExaminationsFDNY Headquarters9 MetroTech CenterBrooklyn, NY 11201-3857(718) 999-1858(718) 999-0088 (fax)Tobacco Cessation Program9 MetroTech CenterBrooklyn, NY 11201-3857Fort Totten Building 413BBayside, NY 11364(718) 999-194256WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 5 • THE FDNY-WORLD TRADE CENTER MENTAL HEALTH TREATMENTPROGRAM POST-9/11/01Many members who worked at the WTC site post-9/11 initially did not allow themselves the time to grieve for thoselost, so mental health problems tended to surface later, once the search slowed and members had more time toprocess their emotions. Due to the nature of the job, FDNY members form tight-knit teams and typically were accustomed to self-management of problems or turning to their team members for advice prior to 9/11. CSU-trained peercounselors provide initial support and encourage members to seek professional counseling and treatment fromtrained mental health practitioners (social workers, psychologists and psychiatrists) at CSU or when needed throughother organizations. Referrals to private practitioners were made for those clients as needed or when preferred. Theincrease in use of FDNY-CSU counseling services after the first year post-9/11 reflects a greater acceptance by ourmembers of the need for more formal, structured counseling. The continued utilization of FDNY-CSU services in theyears that followed indicates that members continue to seek services as they recognize the need for effective treatments. Between 9/12/01 and 6/30/07, there have been 157,406 visits to FDNY-CSU by 11,248 FDNY employeesand family members. Pre-9/11, there were only 600 visits per year to FDNY-CSU. Free mental health medications noware available for those members (Fire and EMS, active and retired) with WTC-related conditions and a recent FDNYWTC Medical monitoring exam.ANNUAL NUMBER OF PATIENTS IN THE FDNY-CSU WTCMENTAL HEALTH TREATMENT PROGRAMThis program includes Fire and EMS (active or retired) and affected familymembers. Use of FDNY-CSU counseling services increased dramatically after9/11/01 and has remained high, demonstrating the needfor continued services.12,00010,00080006000400020000Total Number of PatientsFDNY MembersFamily9/12/01 to06/30/027/1/02 to06/30/037/1/03 to06/30/047/1/04 to06/30/057/1/05 to06/30/067/1/06 to06/30/07TOTAL➤Pre-WTC CSU visits:Annually, 500-600 FDNY rescueworkers➤Post-WTC CSU visits:Annually, approximately 2500FDNY rescue workersSECTION 6CONCLUSIONAppendix A Publication List➤Appendix B Wellness Self-Tests and Tips➤Postscript➤58WorldTradeCenterHealthImpactsonFDNYRescueWorkersSECTION 6CONCLUSIONThe World Trade Center Medical Monitoringand Treatment Program is committed tomonitoring, assessing and treating theimmediate health effects that became evidentshortly after the disaster; the long-term healtheffects that have become prevalent in the yearssince 9/11; and late-emerging diseases that mayoccur in the years that follow. This belief is sharedby Mayor Bloomberg and the members of hisWTC Health Panel, who have been strong advocates of federal resources to fully fund not onlythe FDNY WTC Program, but the Mount SinaiConsortium’s WTC Medical Monitoring andTreatment Program for non-FDNY respondersand the Bellevue Hospital Environmental HealthCenter Treatment Program.This report has presented information on thehealth effects of 9/11, which confirms that theWTC exposure was unique and its effects are farreaching and widespread among FDNY rescueworkers. It is clear that exposures of FDNY personnel require a continued commitment to healthmonitoring and treatment.Thankfully, for many, time and treatment haveallowed medical and psychological problems toresolve or diminish in severity since that fatefulday. Unfortunately, for others, illness persists.Some of these issues continue to present themselves throughout our work force (Fire and EMS,active and retired). Pulmonary function testsdemonstrated an unprecedented decline in lungfunction in the year following September 11,2001. Follow-up studies are in progress to deter-mine the extent to which these declines have con-tinued. Given the nature of the job, respiratorysymptoms, such as shortness of breath, whichmay occur as a result of lung function loss, canimpair our members’ ability to function at work.Similarly, PTSD, depression and anxiety cancause serious problems, both at work and home.The FDNY WTC Program has performed mon-itoring evaluations on more than 14,245 activeand retired FDNY rescue workers. Identifyingthese problems through regular monitoring eval-uations and providing treatment when needed,provide the best chance for preventing emphyse-ma and pulmonary fibrosis and fighting cancerand other late-emerging diseases.Treatment options can take different paths,including specialized procedures, such as chestCAT scans, cardiac stress tests and endoscopies.“Tobacco Free with FDNY” is a nationallyrenowned tobacco cessation program that canhelp those members who wish to “kick the habit.”We urge our members to take advantage of thisprogram. Although we did not find tobacco use“It’s a no-brainer. If you care about yourself andyour family, this is a chance to see about yourcondition, to prevent a condition from worsen-ing or find out if anything has popped up.”Capt. Bill Butler“This is a good program; I highly recommend itto other retirees. The evaluation was very exten-sive, thorough. For retirees with concerns abouttheir future health, they should come down forthis medical evaluation for their piece of mindand for their families, too. There may beunknowns popping up or some problems mayshow accelerated rate, so it’s important to knowwhat is going on. Everyone at BHS treated usprofessionally and in a caring manner."Lt. Dennis O’Berg59WorldTradeCenterHealthImpactsonFDNYRescueWorkersto be associated with WTC-related declines inpulmonary function or with increases in sarcoid,it is well-known that smoking increases the futurerisk of developing cardiopulmonary diseasesand cancer. As of December 1, 2006, the FDNYWTC Program began to offer a free medicationprogram for WTC-related illnesses. We believethat this is an indispensable part of ourTreatment Program, as many of our membersand union security benefits funds (prescriptionplans) have been burdened financially by payingfor WTC medications. By offering medications atno cost, a barrier to care is removed so thathealth outcomes can be improved.We advise all members who worked at any ofthe WTC sites to remain active in the FDNYMonitoring and Treatment Program. Only withearly diagnosis and treatment can there beimprovement in health outcomes and demonstrated need for continued funding of this vitalprogram. Member participation does not beginand end with a visit to BHS; we will be periodically contacting members for case managementfollow-ups and we urge members to contact us ifany new or additional medical or psychologicalissues arise. You are the best source of information about your own well-being and active participation in this program will help us continue towork as a team in maintaining your health.This report has presented the information anddata that we have gathered during the past fiveyears. It is a reflection of how the FDNY hasresponded to meet the needs of our members. Itis clear that we continue to see members whoare still suffering from a variety of ailments thatcan be attributed to this event. It is also clear thatonly with long-term health monitoring and treatment will we learn how this exposure correlateswith the onset of serious long-term diseases,such as emphysema, pulmonary fibrosis andcancer.We wish to thank all those who served so selflessly at the WTC on and after September 11,2001. The WTC Monitoring and TreatmentProgram has been a successful joint labor/management initiative that has served as a model forNew York City. Health and fitness are of paramount importance in fulfilling the mission of protecting life and property in New York City. Ourshared goal continues to be to maximize thephysical and mental health of our work force,both now and in the future. Working together, wewill continue to make progress toward that goal.Our health is a gift that deserves our close attention. Be well and stay safe.60WorldTradeCenterHealthImpactsonFDNYRescueWorkersAPPENDIX A • PUBLICATION LISTAcute Eosinophilic Pneumonia in a New York CityFirefighter Exposed to World Trade Center Dust.ByRom WN, Weiden M, Garcia R, Ting AY, Vathesatogkit P, TseDB, McGuinness G, Roggli V, Prezant DJ, published inAmerican Journal of Respiratory and Critical Care Medicine,July 2002; 166:797-800.Cough and Bronchial Responsiveness in Firefightersat the World Trade Center Site.By Prezant DJ, Weiden M,Banauch GI, McGuinness G, Rom WN, Aldrich TK and Kelly KJ,published in New England Journal of Medicine, September 12,2002; 347:806-15.Injuries and Illnesses Among New York City FireDepartment Rescue Workers After Responding to theWorld Trade Center Attacks.By Banauch GI, McLaughlinM, Hirschhorn R, Corrigan M, Kelly KJ, Prezant DJ, published inMMWR, September 11, 2002; 51:1-5.Use of Respiratory Protection Among Responders atthe World Trade Center Site--New York City,September 2001.By Prezant DJ, Kelly KJ, Jackson B, PetersonD, Feldman D, Baron S, Mueller CA, Bernard B, Lushniak B, SmithL, BerryAnn R, Hoffman B, published in MMWR, September 11,2002; 51:6-8.Persistent Hyperreactivity and Reactive AirwayDysfunction in Firefighters at the World TradeCenter.By Banauch GI, Alleyne D, Sanchez R, Olender K,Weiden M, Kelly KJ, Prezant DJ, published in Am. J. Resp. Crit.Care Med., February 2003; 168:54-62.Biomonitoring of Chemical Exposure Among NewYork City Firefighters Responding to the World TradeCenter Fire and Collapse.By Edelman P, Osterloh J, PirkleJ, Grainger J, Jones R, Blount B, Calafat A, Turner W, Caudill S,Feldman DM, Baron S, Bernard BP, Lushniak BD, Kelly KJ, PrezantDJ, published in Environmental Health Perspectives, September2003; 111:1906-1911.Rising to the Challenge: The Counseling Service Unitof the Fire Department of New York Moves ForwardAfter September 11, 2001.By Corrigan MP, Kelly KJ,Prezant DJ, Hart M, Crawford L, published by FDNY, 2003.Symptoms, Respirator Use, and Pulmonary FunctionChanges Among New York City FirefightersResponding to the World Trade Center Disaster.ByFeldman DM, Baron S, Mueller CA, Bernard BP, Lushniak BD, KellyKJ, Prezant DJ, published in Chest, April 2004; 125:1256-64.Induced Sputum Assessment in New York CityFirefighters Exposed to World Trade Center Dust.ByFireman E, Lerman Y, Ganor E, Greif J, Fireman Shoresh S,Oppenheim E, Flash R, Miller A, Banauch GI, Weiden M, KellyKJ, Prezant DJ, published in Environmental Health Perspectives,November 2004; 112:1564-1569.Bronchial Hyperreactivity and Other Inhalation LungInjuries in Rescue/Recovery Workers After the WorldTrade Center Collapse.By Banauch GI, Dhala A, Alleyne D,Alva R, Santhyadka G, Krasko A, Weiden M, Kelly KJ, Prezant DJ,published in Am. J. Resp. Crit. Care Med., 2005; 33:S102-S106.Pulmonary Disease in Rescue Workers at the WorldTrade Center Site.By Banauch GI, Dhala A, Prezant DJ, published in Curr. Opin. Pulm. Med., 2005; 11:160-8.“Tobacco Free with FDNY” The New York City FireDepartment World Trade Center Tobacco CessationStudy.By Bars MP, Banauch GI, Appel DW, Andreaci M,Mouren P, Kelly KJ, Prezant DJ, published in Chest, April 2006;129:979-987.Pulmonary Function After Exposure to the WorldTrade Center in the New York City Fire Department.By Banauch GI, Hall C, Weiden M, Cohen HW, Aldrich TK,Christodoulou V, Arcentales N, Kelly KJ, Prezant DJ, published inAm. J. Resp. Crit. Care Med., August 2006; 174:312-319.FDNY Crisis Counseling: Innovative Responses to9/11 Firefighters, Families, and Communities.ByGreene P, Kane D, Christ G, Lynch S, Corrigan M, published byJohn Wiley & Sons Inc., Hoboken; 2006.World Trade Center Sarcoid-Like GranulomatousPulmonary Disease in NYC Fire Rescue Workers.By IzbickiG, Chauko R, Banauch GI, Weiden M, Berger K, Kelly KJ, Aldrich TK,Prezant DJ, published in Chest, April 2007;131:1414-1423.61APPENDIX B • WELLNESS SELF-TESTS AND TIPSWorldTradeCenterHealthImpactsonFDNYRescueWorkersWe are very concerned about your health as WTC responders. These health quizzes are for your personal use and maybe able to help you identify WTC-related illness. We hopethis information will facilitate your decision on whether selfreferral to FDNY-BHS or your own physician is necessary.Have you experienced any upper respiratory conditions?NOT COUNTING WHEN YOU HAVE A COLD, please puta check in the box next to any problems you have had inTHE PAST 4 WEEKS OR REPEATEDLY IN THE PAST 12MONTHS.❏Nose irritation, soreness or burning❏Runny nose or postnasal drip❏Frequent nosebleeds❏Nasal or sinus congestion❏Sinus or face pain or pressure❏Frequent headachesHave you experienced any gastro-intestinal conditions?Please put a check in the box next to any problems you havehad in THE PAST 4 WEEKS OR REPEATEDLY IN THE PAST12 MONTHS.❏Difficulty swallowing (feels like food gets stuck)❏Coughing after you lie down or eat❏Frequent nausea (at least 2 times per week)❏Frequent sour or acid taste in the mouth (at least 2times per week)❏Frequent acid reflux/regurgitation into mouth(at least 2 times per week)❏Frequent heartburn/indigestion (at least 2 times perweek)Have you experienced any lower respiratory conditions? Please put a check in the box next to any problems you have had in THE PAST 4 WEEKS ORREPEATEDLY IN THE PAST 12 MONTHS.❏Wheezing or whistling in your chest❏Difficulty taking in a full breath❏Shortness of breath❏Frequent or usual cough (at least 4 times per day,4 days per week, 4 consecutive weeks per year)Have you experienced these symptoms when exposedto IRRITANTS? Please put a check in the box next toanything that has provoked your lower respiratorysymptoms in THE PAST 4 WEEKS OR REPEATEDLY INTHE PAST 12 MONTHS.❏Exercise or physical activity❏Strong odors❏Dust❏Allergens❏Temperature or humidity extremes❏Smoke or fumesThe checklist above is not a formal diagnostic tool. Itis simply a list of symptoms associated with WTCrelated illnesses. If you put a check in the box next toMORE THAN ONE of these problems and you werepresent at one of the WTC sites, you may have aWTC-related illness. Only a health care professionalcan formally diagnose this condition. Please contactyour doctor or call the FDNY-WTC MedicalMonitoring and Treatment Program at 718-999-1858 to make a treatment appointment.PLEASE TAKE THIS PERSONAL HEALTH QUIZ62WorldTradeCenterHealthImpactsonFDNYRescueWorkersAPPENDIX B • WELLNESS SELF-TESTS AND TIPSDuring the past 2 weeks, have you been bothered byany of the following problems? Please put a check in thebox next to any problems you have.❏Little interest or pleasure in doing things❏Feeling down, depressed or hopeless❏Sleep difficulties❏Fatigue or lack of energy❏Change in appetite❏Feeling worthless or that you are a failure❏Difficulty concentrating❏Lack of motivation❏Feeling restless or fidgety❏Suicidal thoughtsDo these symptoms affect your ability to function, eitherat home or work?❏Yes❏NoThe checklist above is not a formal diagnostic tool. It issimply a list of symptoms associated with depression. Ifyou put a check in the box next to MORE THAN ONEof these problems, you may have depression. Only ahealth care professional can formally diagnose this condition. Please contact your doctor or the FDNYCounseling Services Unit to find out what treatmentoptions are available. A list of CSU locations and phonenumbers can be found on this page. If you put a checkin the box next to suicidal thoughts, you should call yourdoctor or the FDNY counseling unit 24-hour phone lineimmediately at 212-570-1693.Have you lived through a scary and dangerous lifethreatening event? Please put a check in the box next toany problems you have had in THE PAST MONTH.❏I feel like the terrible event is happening all overagain. This feeling often comes without warning.❏I have nightmares and scary memories of the event.❏I stay away from places that remind me of the event.❏I jump and feel very upset when something happenswithout warning.❏I have a hard time trusting or feeling close to otherpeople.❏I get mad very easily.❏I feel guilty because others died and I lived.❏I have trouble sleeping and my muscles are tense.Do these symptoms affect your ability to function, eitherat home or work?❏Yes❏NoThe checklist above is not a formal diagnostic tool. It issimply a list of symptoms associated with Post-TraumaticStress Disorder (PTSD). If you put a check in the box toMORE THAN ONE of these problems, you may havePTSD. Only a health care professional can formally diagnose this condition. Please contact your doctor or theFDNY Counseling Services Unit to find out what treatment options are available. A list of CSU locations andphone numbers can be found on this page.PLEASE TAKE THIS PERSONAL HEALTH QUIZFDNY-CSU LocationsManhattan Counseling Unit251 Lafayette Street, 3rd Fl, NYC 10012(212) 570-1693 (24-Hour Line)Staten Island Counseling Unit1688 Victory BoulevardStaten Island, NY 10314(718) 815-4111Fort Totten Counseling UnitFort Totten Building 413ABayside, NY 11364(718) 352-2140Brentwood Counseling UnitLiberty Project CenterSuffolk County Community CollegeCrooked Hill Road,Brentwood, NY 11717(631) 851-6888Orange County Counseling Unit2279 Goshen TurnpikeMiddletown, NY 10941(845) 695-1029Substance Abuse Day-TreatmentProgram594 Broadway, Suite 500(212) 925-6671FDNY Headquarters9 MetroTech CenterBrooklyn, NY 11201-3857(718) 999-1858(718) 999-0088 (fax)Medical Monitoring ExaminationsFDNY Headquarters9 MetroTech CenterBrooklyn, NY 11201-3857(718) 999-1858(718) 999-0088 (fax)Tobacco Cessation Program9 MetroTech CenterBrooklyn, NY 11201-3857Fort Totten Building 413BBayside, NY 11364(718) 999-194263WorldTradeCenterHealthImpactsonFDNYRescueWorkersWe are all concerned about WTC-related respiratory andmental health diseases. Cancer and heart disease are concerns for all Firefighters and many of us are concerned thatWTC exposures will have a further negative impact.Although none of us can take back our past exposures,there are many steps we can take to reduce our risk fordeveloping illness in the future.Wellness involves the health of the whole person. The bodymust be kept strong, fit and well-nourished, so it’s able toresist disease and overcome injury. This is a team effort,combining mind, body and spirit. Wellness is more thanjust not being sick--it’s a positive state of health. Wellnessmeans taking responsibility for your own health by:1.Learn how to stay healthy·Have an annual medical examination.·Respond to your body’s warning signs and visit yourhealth-care provider--before something serioushappens.·Get an annual influenza vaccination.·Get a pneumococcal vaccination, especially recommended for those with pulmonary disease.2.Practice good health habits and give up harmful ones·Quit smoking now! Eliminate exposure to secondhand smoke. For help quitting, please call the FDNYTobacco Cessation Program at 718-999-1942.·Avoid alcohol abuse and drug use.·Avoid occupational or recreational exposures thatare known to exacerbate illness. Always wear yourmask.·Get enough exercise. Adults need at least 30 minutes of physical activity on most days of the week.·Practice safe sex with a loved one.·Eat right. Make smart choices from each foodgroup every day. If you have gastroesophagealreflux disease (GERD), diet modification and weightcontrol are integral to the management of this disease. Don’t eat for 2 hours before lying down andavoid caffeine, carbonated beverages, chocolate,alcohol, spices, tomatoes and citrus fruits/juice.3.Learn how to manage stress·Try to relax. Go to a movie, a ball game or participate in religious, social or other activities that maymake you feel better.·Improve your environment. Small changes aroundyour home or office help you feel in control.·Plan your work to make efficient use of your timeand energy.·Be realistic. Set practical goals for yourself.·Try to be with other people and confide in someone.It is usually better than being alone and secretive.·Seek professional help. Don’t ignore symptoms ofstress.Focus on your own wellness. You can be healthier, feelbetter, look better and live longer!In August 2006, the New York City Department of Healthand Mental Hygiene released Clinical Guidelines forAdults Exposed to the World Trade Center Disaster. Dueto the fact that many New Yorkers have health problemsthat may be associated with WTC exposure, it is essentialthat primary care physicians know how to identify, evaluate, treat and possibly refer these individuals to specialists. The publication suggests how clinicians can determine a patient’s exposure history and identifies manyhealth problems that may have been caused or madeworse by WTC exposure. It also offers algorithms to helpclinicians diagnose, treat and manage WTC-related conditions. The guidelines are included with this book. Youcan give them to your personal doctor if you so desire.Your doctor also can download them from the NYCDepartment of Health and Mental Hygiene website at:http://www.nyc.gov/html/doh/downloads/pdf/chi/chi25-7.pdf.Wellness TipsWHAT YOU CAN DO TO START THE HEALINGPROCESSAPPENDIX B • WELLNESS SELF-TESTS AND TIPS“I think if you have no symptoms atrest, exercise, stress or work and youhave been in our monitoring program,then you are fine, but need to continuemonitoring in case late-emerging diseases occur. However, if you havesymptoms or abnormal findings fromthe monitoring program, then youshould be evaluated for treatment.”Dr. David Prezant64“When you have a Department whose men and women are expected to be ready atany moment to put their lives on the line, to go to the aid of a stranger, even when itmeans that you may put yourself in dire peril, I don’t think you can pay people to dothat job. There has to be something beyond money that makes them do that.”William M. FeehanFirst Deputy Fire Commissioner & Former Chief of DepartmentMade the Supreme Sacrifice on 9/11/01“I am proud of this Department. But, I am most proud of the men and women--Firefighters, Officers, Fire Marshals, Paramedics/EMTs, Inspectors and all the dedicated support staff--who so selflessly perform their jobs, often placing themselves at risk,to ensure the health and safety of all New Yorkers and the millions who visit this greatCity each year.”Peter J. Ganci, Jr., Chief of DepartmentMade the Supreme Sacrifice on 9/11/01“You’ll have good days and bad days, up days and down days, sad days and happydays, but never a boring day on this job. You’ll love this job. What a blessing that is!A difficult job and God calls you to it and gives you a love for it, so that a difficult jobwill be well-done.”Father Mychal Judge, OFM, FDNY ChaplainMade the Supreme Sacrifice on 9/11/01POSTSCRIPT • A SALUTE TO THE RESCUE WORKERS FROM THOSE WHO MADETHE SUPREME SACRIFICE ON 9/11/01The9/11MemorialWaterfordCrystalThe sculpture, which depicts the recovery ofFDNY Chaplain Father Mychal Judge, tookmore than 200 hours to create. It was presented to FDNY at the quarters of Engine 1/Ladder24. The firehouse is located directly across thestreet from the friary at St. Francis of AssisiChurch, where Father Mychal Judge resided.WorldTradeCenterHealthImpactsonFDNYRescueWorkersNew York City Fire Department MembersWho Made The Supreme SacrificeIn The Performance of DutyAt The World Trade CenterSeptember 11, 2001Manhattan Box 5-5-8087First Deputy Commissioner William M. FeehanOffice of Fire CommissionerChief of Department Peter J. Ganci, Jr., CODAssistant Chief Gerard A. Barbara, OperationsAssistant Chief Donald J. Burns, OperationsDeputy Chief Dennis A. Cross, Battalion 57Deputy Chief Raymond M. Downey, SOCDeputy Chief Edward F. Geraghty, Battalion 9Department Chaplain Mychal F. Judge, OFMDeputy Chief Charles L. Kasper, SOCDeputy Chief Joseph R. Marchbanks, Jr., Battalion 12Deputy Chief Orio J. Palmer, Battalion 7Deputy Chief John M. Paolillo, SOCBattalion Chief James M. Amato, Squad Co. 1Battalion Chief Thomas P. DeAngelis, Battalion 8Battalion Chief Dennis L. Devlin, Division 3Battalion Chief John J. Fanning, Haz-Mat OperationsBattalion Chief Thomas J. Farino, Engine Co. 26Battalion Chief Joseph D. Farrelly, Engine Co. 4Battalion Chief Joseph Grzelak, Battalion 48Battalion Chief Thomas T. Haskell, Jr., Ladder Co. 132Battalion Chief Brian C. Hickey, Rescue Co. 4Battalion Chief William J. McGovern, Battalion 2Battalion Chief Louis J. Modafferi, Rescue Co. 5Battalion Chief John M. Moran, SOCBattalion Chief Richard A. Prunty, Battalion 2Battalion Chief Matthew L. Ryan, Battalion 4Battalion Chief Fred C. Scheffold, Battalion 12Battalion Chief Lawrence T. Stack, Safety Battalion 1Battalion Chief John P. Williamson, Battalion 6Captain Daniel J. Brethel, Ladder Co. 24Captain Patrick J. Brown, Ladder Co. 3Captain Vincent E. Brunton, Ladder Co. 105Captain William F. Burke, Jr., Engine Co. 21Captain Frank J. Callahan, Ladder Co. 35Captain Martin J. Egan, Jr., Ladder Co. 118Captain Michael A. Esposito, Squad Co. 1Captain John R. Fischer, Ladder Co. 20Captain Vincent F. Giammona, Ladder Co. 5Captain Terence S. Hatton, Rescue Co. 1Captain Walter G. Hynes, Ladder Co. 13Captain Frederick J. Ill, Jr., Ladder Co. 2Captain William E. McGinn, Squad Co. 18Captain Thomas C. Moody, Engine Co. 310Captain Daniel O’Callaghan, Ladder Co. 4Captain William S. O’Keefe, Engine Co. 154Captain Vernon A. Richard, Ladder Co. 7Captain Timothy M. Stackpole, Ladder Co. 103Captain Patrick J. Waters, Haz-Mat Co. 1Captain David T. Wooley, Ladder Co. 4Lieutenant Joseph Agnello, Ladder Co. 118Lieutenant Brian G. Ahearn, Engine Co. 230Lieutenant Gregg Atlas, Engine Co. 10Lieutenant Steven J. Bates, Engine Co. 235Lieutenant Carl J. Bedigian, Engine Co. 214Lieutenant John A. Crisci, Haz-Mat Co. 1Lieutenant Edward A. D’Atri, Squad Co. 1Lieutenant Manuel Del Valle, Jr., Engine Co. 5Lieutenant Andrew J. Desperito, Engine Co. 1Lieutenant Kevin W. Donnelly, Ladder Co. 3Lieutenant Kevin C. Dowdell, Rescue Co. 4Lieutenant Michael N. Fodor, Ladder Co. 21Lieutenant David J. Fontana, Squad Co. 1Lieutenant Andrew A. Fredericks, Squad Co. 18Lieutenant Peter L. Freund, Engine Co. 55Lieutenant Charles W. Garbarini, Ladder Co. 61Lieutenant Ronnie E. Gies, Squad Co. 288Lieutenant John F. Ginley, Engine Co. 40Lieutenant Geoffrey E. Guja, Engine Co. 82Lieutenant Joseph P. Gullickson, Ladder Co. 101Lieutenant David Halderman, Squad Co. 18Lieutenant Vincent G. Halloran, Ladder Co. 8Lieutenant Harvey L. Harrell, Rescue Co. 5Lieutenant Stephen G. Harrell, Ladder Co. 157Lieutenant Michael K. Healey, Squad Co. 41Lieutenant Timothy B. Higgins, Squad Co. 252Lieutenant Anthony M. Jovic, Ladder Co. 34Lieutenant Thomas R. Kelly, Ladder Co. 105Lieutenant Ronald T. Kerwin, Squad Co. 288Lieutenant Joseph G. Leavey, Ladder Co. 15Lieutenant Michael F. Lynch, Ladder Co. 4Lieutenant Patrick J. Lyons, Squad Co. 252Lieutenant Charles J. Margiotta, Ladder Co. 85Lieutenant Peter C. Martin, Rescue Co. 2Lieutenant Paul R. Martini, Engine Co. 201Lieutenant Paul T. Mitchell, Ladder Co. 110Lieutenant Dennis Mojica, Rescue Co. 1Lieutenant Raymond E. Murphy, Ladder Co. 16Lieutenant Robert B. Nagel, Engine Co. 58Lieutenant John P. Napolitano, Rescue Co. 2Lieutenant Thomas G. O’Hagan, Engine Co. 52Lieutenant Glenn C. Perry, Ladder Co. 34Lieutenant Philip S. Petti, Ladder Co. 148Lieutenant Kevin J. Pfeifer, Engine Co. 33Lieutenant Kenneth J. Phelan, Engine Co. 217Lieutenant Michael T. Quilty, Ladder Co. 11Lieutenant Robert M. Regan, Ladder Co. 118Lieutenant Michael T. Russo, Squad Co. 1Lieutenant Christopher P. Sullivan, Ladder Co. 111Lieutenant Robert F. Wallace, Engine Co. 205Lieutenant Jeffrey P. Walz, Ladder Co. 9Lieutenant Michael P. Warchola, Ladder Co. 5Lieutenant Glenn E. Wilkinson, Engine Co. 238Fire Marshal Ronald P. Bucca, Manhattan BaseFire Marshal Andre G. Fletcher, Rescue Co. 5Fire Marshal Vincent D. Kane, Engine Co. 22Fire Marshal Kenneth B. Kumpel, Ladder Co. 25Fire Marshal Paul J. Pansini, Engine Co. 10Firefighter Eric T. Allen, Squad Co. 18Firefighter Richard D. Allen, Ladder Co. 15Firefighter Calixto Anaya, Jr., Engine Co. 4Firefighter Joseph J. Angelini, Sr., Rescue Co. 1Firefighter Joseph J. Angelini, Jr., Ladder Co. 4Firefighter Faustino Apostol, Jr., Battalion 2Firefighter David G. Arce, Engine Co. 33Firefighter Louis Arena, Ladder Co. 5Firefighter Carl F. Asaro, Battalion 9Firefighter Gerald T. Atwood, Ladder Co. 21Firefighter Gerard Baptiste, Ladder Co. 9Firefighter Matthew E. Barnes, Ladder Co. 25Firefighter Arthur T. Barry, Ladder Co. 15Firefighter Stephen E. Belson, Ladder Co. 24Firefighter John P. Bergin, Rescue Co. 5Firefighter Paul M. Beyer, Engine Co. 6Firefighter Peter A. Bielfeld, Ladder Co. 42Firefighter Brian E. Bilcher, Engine Co. 33Firefighter Carl V. Bini, Rescue Co. 5Firefighter Christopher J. Blackwell, Rescue Co. 3Firefighter Michael L. Bocchino, Battalion 48Firefighter Frank J. Bonomo, Engine Co. 230Firefighter Gary R. Box, Squad Co. 1Firefighter Michael Boyle, Engine Co. 33Firefighter Kevin H. Bracken, Engine Co. 40Firefighter Michael E. Brennan, Ladder Co. 4Firefighter Peter Brennan, Squad Co. 288Firefighter Andrew C. Brunn, Ladder Co. 5Firefighter Gregory J. Buck, Engine Co. 201Firefighter John P. Burnside, Ladder Co. 20Firefighter Thomas M. Butler, Squad Co. 1Firefighter Patrick D. Byrne, Ladder Co. 101Firefighter George C. Cain, Ladder Co. 7Firefighter Salvatore B. Calabro, Ladder Co. 101Firefighter Michael F. Cammarata, Ladder Co. 11Firefighter Brian Cannizzaro, Ladder Co. 101Firefighter Dennis M. Carey, Haz-Mat Co. 1Firefighter Michael S. Carlo, Engine Co. 230Firefighter Michael T. Carroll, Ladder Co. 3Firefighter Peter J. Carroll, Squad Co. 1Firefighter Thomas A. Casoria, Engine Co. 22Firefighter Michael J. Cawley, Ladder Co. 136Firefighter Vernon P. Cherry, Ladder Co. 118Firefighter Nicholas P. Chiofalo, Engine Co. 235Firefighter John G. Chipura, Engine Co. 219Firefighter Michael J. Clarke, Ladder Co. 2Firefighter Steven Coakley, Engine Co. 217Firefighter Tarel Coleman, Squad Co. 252Firefighter John M. Collins, Ladder Co. 25Firefighter Robert J. Cordice, Engine Co. 152Firefighter Ruben D. Correa, Engine Co. 74Firefighter James R. Coyle, Ladder Co. 3Firefighter Robert J. Crawford, Safety Battalion 1Firefighter Thomas P. Cullen, III, Squad Co. 41Firefighter Robert Curatolo, Ladder Co. 16Firefighter Michael D. D’Auria, Engine Co. 40Firefighter Scott M. Davidson, Ladder Co. 118Firefighter Edward J. Day, Ladder Co. 11Firefighter Martin N. DeMeo, Haz-Mat Co. 1Firefighter David P. DeRubbio, Engine Co. 226Firefighter Gerard P. Dewan, Ladder Co. 3Firefighter George DiPasquale, Ladder Co. 2Firefighter Gerard J. Duffy, Ladder Co. 21Firefighter Michael J. Elferis, Engine Co. 22Firefighter Francis Esposito, Engine Co. 235Firefighter Robert E. Evans, Engine Co. 33Firefighter Terrence P. Farrell, Rescue Co. 4Firefighter Lee S. Fehling, Engine Co. 235Firefighter Alan D. Feinberg, Battalion 9Firefighter Michael C. Fiore, Rescue Co. 5Firefighter John J. Florio, Engine Co. 214Firefighter Thomas J. Foley, Rescue Co. 3Firefighter Robert J. Foti, Ladder Co. 7Firefighter Thomas Gambino, Jr., Rescue Co. 3Firefighter Thomas A. Gardner, Haz-Mat Co. 1Firefighter Matthew D. Garvey, Squad Co. 1Firefighter Bruce H. Gary, Engine Co. 40Firefighter Gary P. Geidel, Rescue Co. 1Firefighter Denis P. Germain, Ladder Co. 2Firefighter James A. Giberson, Ladder Co. 35Firefighter Paul J. Gill, Engine Co. 54Firefighter Jeffrey J. Giordano, Ladder Co. 3Firefighter John J. Giordano, Engine Co. 37Firefighter Keith A. Glascoe, Ladder Co. 21Firefighter James M. Gray, Ladder Co. 20Firefighter Jose A. Guadalupe, Engine Co. 54Firefighter Robert W. Hamilton, Squad Co. 41Firefighter Sean S. Hanley, Ladder Co. 20Firefighter Thomas P. Hannafin, Ladder Co. 5Firefighter Dana R. Hannon, Engine Co. 26Firefighter Daniel E. Harlin, Ladder Co. 2Firefighter Timothy S. Haskell, Squad Co. 18Firefighter Michael H. Haub, Ladder Co. 4Firefighter John F. Heffernan, Ladder Co. 11Firefighter Ronnie L. Henderson, Engine Co. 279Firefighter Joseph P. Henry, Ladder Co. 21Firefighter William L. Henry, Rescue Co. 1Firefighter Thomas J. Hetzel, Ladder Co. 13Firefighter Jonathan R. Hohmann, Haz-Mat Co. 1Firefighter Thomas P. Holohan, Engine Co. 6Firefighter Joseph G. Hunter, Squad Co. 288Firefighter Jonathan L. Ielpi, Squad Co. 288Firefighter William R. Johnston, Engine Co. 6Firefighter Andrew B. Jordan, Ladder Co. 132Firefighter Karl H. Joseph, Engine Co. 207Firefighter Angel L. Juarbe, Jr., Ladder Co. 12Firefighter Paul H. Keating, Ladder Co. 5Firefighter Richard J. Kelly, Jr., Ladder Co. 11Firefighter Thomas W. Kelly, Ladder Co. 15Firefighter Thomas J. Kennedy, Ladder Co. 101Firefighter Michael V. Kiefer, Ladder Co. 132Firefighter Robert C. King, Jr., Engine Co. 33Firefighter Scott M. Kopytko, Ladder Co. 15Firefighter William E. Krukowski, Ladder Co. 21Firefighter Thomas J. Kuveikis, Squad Co. 252Firefighter David J. LaForge, Ladder Co. 20Firefighter William D. Lake, Rescue Co. 2Firefighter Robert T. Lane, Engine Co. 55Firefighter Peter J. Langone, Squad Co. 252Firefighter Scott A. Larsen, Ladder Co. 15Firefighter Neil J. Leavy, Engine Co. 217Firefighter Daniel F. Libretti, Rescue Co. 2Firefighter Robert T. Linnane, Ladder Co. 20Firefighter Michael F. Lynch, Engine Co. 40Firefighter Michael J. Lyons, Squad Co. 41Firefighter Joseph Maffeo, Ladder Co. 101Firefighter William J. Mahoney, Rescue Co. 4Firefighter Joseph E. Maloney, Ladder Co. 3Firefighter Kenneth J. Marino, Rescue Co. 1Firefighter John D. Marshall, Engine Co. 23Firefighter Joseph A. Mascali, Rescue Co. 5Firefighter Keithroy M. Maynard, Engine Co. 33Firefighter Brian G. McAleese, Engine Co. 226Firefighter John K. McAvoy, Ladder Co. 3Firefighter Thomas J. McCann, Engine Co. 65Firefighter Dennis P. McHugh, Ladder Co. 13Firefighter Robert D. McMahon, Ladder Co. 20Firefighter Robert W. McPadden, Engine Co. 23Firefighter Terence A. McShane, Ladder Co. 101Firefighter Timothy P. McSweeney, Ladder Co. 3Firefighter Martin E. McWilliams, Engine Co. 22Firefighter Raymond M. Meisenheimer, Rescue Co. 3Firefighter Charles R. Mendez, Ladder Co. 7Firefighter Steve J. Mercado, Engine Co. 40Firefighter Douglas C. Miller, Rescue Co. 5Firefighter Henry A. Miller, Jr., Ladder Co. 105Firefighter Robert J. Minara, Ladder Co. 25Firefighter Thomas Mingione, Ladder Co. 132Firefighter Manuel Mojica, Squad Co. 18Firefighter Carl E. Molinaro, Ladder Co. 2Firefighter Michael G. Montesi, Rescue Co. 1Firefighter Vincent S. Morello, Ladder Co. 35Firefighter Christopher M. Mozzillo, Engine Co. 55Firefighter Richard T. Muldowney, Jr., Ladder Co. 7Firefighter Michael D. Mullan, Ladder Co. 12Firefighter Dennis M. Mulligan, Ladder Co. 2Firefighter Peter A. Nelson, Rescue Co. 4Firefighter Gerard T. Nevins, Rescue Co. 1Firefighter Dennis P. O’Berg, Ladder Co. 105Firefighter Douglas E. Oelschlager, Ladder Co. 7Firefighter Joseph J. Ogren, Ladder Co. 3Firefighter Samuel P. Oitice, Ladder Co. 4Firefighter Patrick J. O’Keefe, Rescue Co. 1Firefighter Eric T. Olsen, Ladder Co. 15Firefighter Jeffrey J. Olsen, Engine Co. 10Firefighter Steven J. Olson, Ladder Co. 3Firefighter Kevin M. O’Rourke, Rescue Co. 2Firefighter Michael J.Otten, Ladder Co. 35Firefighter Jeffrey A. Palazzo, Rescue Co. 5Firefighter Frank Palombo, Ladder Co. 105Firefighter James N. Pappageorge, Engine Co. 23Firefighter Robert E. Parro, Engine Co. 8Firefighter Durrell V. Pearsall, Rescue Co. 4Firefighter Christopher J. Pickford, Engine Co. 201Firefighter Shawn E. Powell, Engine Co. 207Firefighter Vincent A. Princiotta, Ladder Co. 7Firefighter Kevin M. Prior, Squad Co. 252Firefighter Lincoln Quappe, Rescue Co. 2Firefighter Leonard J. Ragaglia, Engine Co. 54Firefighter Michael P. Ragusa, Engine Co. 279Firefighter Edward J. Rall, Rescue Co. 2Firefighter Adam D. Rand, Squad Co. 288Firefighter Donald J. Regan, Rescue Co. 3Firefighter Christian Regenhard, Ladder Co. 131Firefighter Kevin O. Reilly, Engine Co. 207Firefighter James C. Riches, Engine Co. 4Firefighter Joseph R. Rivelli, Jr., Ladder Co. 25Firefighter Michael E. Roberts, Engine Co. 214Firefighter Michael E. Roberts, Ladder Co. 35Firefighter Anthony Rodriguez, Engine Co. 279Firefighter Matthew S. Rogan, Ladder Co. 11Firefighter Nicholas P. Rossomando, Rescue Co. 5Firefighter Paul G. Ruback, Ladder Co. 25Firefighter Stephen Russell, Engine Co. 55Firefighter Thomas E. Sabella, Ladder Co. 13Firefighter Christopher A. Santora, Engine Co. 54Firefighter John A. Santore, Ladder Co. 5Firefighter Gregory T. Saucedo, Ladder Co. 5Firefighter Dennis Scauso, Haz-Mat Co. 1Firefighter John A. Schardt, Engine Co. 201Firefighter Thomas G. Schoales, Engine Co. 4Firefighter Gerard P. Schrang, Rescue Co. 3Firefighter Gregory R. Sikorsky, Squad Co. 41Firefighter Stephen G. Siller, Squad Co. 1Firefighter Stanley S. Smagala, Jr., Engine Co. 226Firefighter Kevin J. Smith, Haz-Mat Co. 1Firefighter Leon Smith, Jr., Ladder Co. 118Firefighter Robert W. Spear, Jr., Engine Co. 26Firefighter Joseph P. Spor, Rescue Co. 3Firefighter Gregory M. Stajk, Ladder Co. 13Firefighter Jeffrey Stark, Engine Co. 230Firefighter Benjamin Suarez, Ladder Co. 21Firefighter Daniel T. Suhr, Engine Co. 216Firefighter Brian E. Sweeney, Rescue Co. 1Firefighter Sean P. Tallon, Ladder Co. 10Firefighter Allan Tarasiewicz, Rescue Co. 5Firefighter Paul A. Tegtmeier, Engine Co. 4Firefighter John P. Tierney, Ladder Co. 9Firefighter John J. Tipping, II, Ladder Co. 4Firefighter Hector L. Tirado, Jr., Engine Co. 23Firefighter Richard B. Van Hine, Squad Co. 41Firefighter Peter A. Vega, Ladder Co. 118Firefighter Lawrence G. Veling, Engine Co. 235Firefighter John T. Vigiano, II, Ladder Co. 132Firefighter Sergio G. Villanueva, Ladder Co. 132Firefighter Lawrence J. Virgilio, Squad Co. 18Firefighter Kenneth T. Watson, Engine Co. 214Firefighter Michael T. Weinberg, Engine Co. 1Firefighter David M. Weiss, Rescue Co. 1Firefighter Timothy M. Welty, Squad Co. 288FirefighterEugene M. Whelan, Engine Co. 230Firefighter Edward J. White, Engine Co. 230Firefighter Mark P. Whitford, Engine Co. 23FirefighterRaymond R. York, Engine Co. 285EMS Lieutenant Ricardo J. Quinn, EMSBattalion 57ParamedicCarlos R. Lillo, EMS Battalion 49TENHOUSE9/11WTCMEMORIALBRONZEFire Department, City of New York9 MetroTech CenterBrooklyn, New York 11201www.nyc.gov/fdny