FIRE DEPARTMENT, CITY OF NEW 

BUREAU OF

HEALTH

SERVICES

WTC MEDICAL

MONITORING & TREATMENT

Michael R. Bloomberg, Mayor Nicholas Scoppetta, Commissioner

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Kerry Kelly, 

David Prezant, M

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FDNY WTC MEDICAL MON

Justin Niles

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Each 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 

The Towers of Light stand as a memorial, a symbol of hope and resiliency and a reclam

The purpose of this publication is to share important information the Departmen

concerning the physical and mental health effects of 9/11 on our memb

W ORLD ORLD T RADE RADE C ENTER ENTER H EALTH EALTH I MP

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O N O N FDNY R ESCUE ESCUE W ORKERS ORKERS

A Six-Year Assessment: September 2001-September 200

Kelly KJ, Niles J, McLaughlin MT, Carroll S, Co

World Trade Center Health Impacts on FDNY 

September 2001-September 2007. Fir

Preface: Letters

Mayor 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 . . . . . . . . . . . . . . . . . . . . . . .9

Section 1: Introduction & Time Line . . . . . . . . . . . .11

Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12History of the FDNY WTC Program . . . . . . . . . . .12Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Time Line: BHS WTC Program . . . . . . . . . . . . . . . . . . .14Section 2: Medical and Exposure Assessment . . .21

Medical Questionnaire Data

Arrival Time at WTC . . . . . . . . . . . . . . . . . . . . . .23Mask/Respirator Use . . . . . . . . . . . . . . . . . . . . . .24Eye and Skin Irritation Post-WTC . . . . . . . . . . . . .25Respiratory Symptoms for 

Different Exposure Groups... . . . . . . . . . . . . . .26

Lower Respiratory Symptoms . . . . . . . . . . . . . . . .27Upper Respiratory Symptoms . . . . . . . . . . . . . . . .28

Scientific Test Results

Pulmonary Function Loss (by Arrival Time) . . . . . . .29Pulmonary Function Loss 

by Work Assignment (FIRE & EMS). . . . . . . . . .30

Methacholine Challenge Testing 

Hyperreactive Subjects . . . . . . . . . . . . . . . . . .31

Disease Surveillance

“Sarcoid-Like” Granulomatous Pneumonitis . . . . .32

2

Table of Contents

World Trade Center Health Impacts on FDNY Rescue Workers

Section 3: Mental Health Asses

Mental Health Questionn

FDNY WTC Survivors Clo

Lost on 9/11/01 . . . 

WTC-Related Health ConWTC-Related Concerns A

by Arrival Time . . . . . 

Change in Sleep-Related Change in Mood After WFeelings of Distance and Reliving and RememberinChange in Exercise Progr

Section 4: FDNY Retirement an

FDNY Retirements and YDisability Pensions Recei

Number of Pulmonary CaNumber of Permanent Psy

Impairment Cases . . 

Number of Cardiac CaseNumber of Cancer Cases NYCERS EMS “3/4” Disa

Applications Approved 

Section 5: The FDNY-WTC-MMTP 

Number of Monitoring ExAnnual Number of Patien

Medical Treatment Pro

Tobacco Cessation SucceCSU Provides Counseling Annual Number of PatienWTC Mental Health Treat

Section 6: Conclusion . . . . . . . . . 

Appendix A Publication List Appendix B Wellness Self-TPostscript . . . . . . . . . . . . For your doctor--NYC DOAdults Exposed to the Wo

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Attachment:
3

Message from the Mayor of the City of New York

Michael R. Bloomberg

In the hours, days, weeks and months following the terrorist attacks on the World Trade Center, New York City 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.

World Trade Center 
4

When the World Trade Center collapsed on 9/11, it unleashed a cloud 

debris the likes of which this City had never seen before. Amonunknowns in the aftermath of that terrible day, one that loomed partwas the question of how that cloud would affect our members’ 

FDNY’s Chief Medical Officers, Drs. Kerry Kelly and David Prezant, realized almosly after the attack that the short- and long-term effects of exposure to the World Tsite needed to be monitored. Together with a host of partners--from Fire and EMS uNational Institute of Occupational Safety & Health (NIOSH)--they created a prograly tailored to the needs of our members. It monitors not only the medical, but also logical effects that this catastrophe had, and continues to have, on our first responMore than 14,200 FDNY first responders have been examined by BHS during the paThis report presents the data culled from those examinations in a clear, understandThese objective data were an important part of the Mayor’s WTC Health Panel’s and recommendations contained in the report, “Addressing the Health Impacts oinformation contained in both of these reports will help us not only deliver the hethat best fit our members’ needs, but also help ensure future funding by presenting sive data on our needs.To those who labored at the WTC site, this report comes with a pledge: We will convide our members with the best medical and psychological monitoring and treatmeas it is needed.Message from the Fire CommissionerNicholas Scoppetta

World Trade Center Health Impacts on FDNY Rescue Workers
5

For 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 their lives. I witnessed firsthand the many days, nights, weekends and holidays our Firefighters spent there, under physically and mentally grueling conditions. It was a painful time that

none 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 Department

Salvatore J. Cassano

World Trade Center 
Dear FDNY Community:

Iam pleased to see the important work of the FDNY compiled in this new 

Occupational Safety and Health (NIOSH) has provided funding since 2002 to itoring and treatment. As Director of NIOSH, I became aware shortly after 9/and others were deeply concerned with the question of whether exposures to 

Zero posed ongoing risks for adverse health effects. It also became clear that robuclinical assessments, were key for identifying symptoms and trends in health effecanswer the question.Since that time, I have had the opportunity to meet many of you I have been touched by your stories of heroism, hope and faith. FDNY has been questions about health effects associated with WTC exposures. Early on, as a parFDNY provided medical screening and monitoring of responders. Those efforts lainitiatives to identify trends in illness among FDNY responders, both individually astudies that are invaluable for furthering our collective knowledge and to guide tonly provides needed medical care, it also captures data that will help us develohealth outcomes, greatly increasing the ability to identify, prevent and treat illnesseI am impressed by the quality of the program, as reflected by the contents of this bued partnership with you, FDNY, and others to answer the questions that concern 

Sincerely,

Letter from John Howard, MD, DirectorNational Institute for Occupational Safety and HealthCenters for Disease Control and Prevention

World Trade Center Health Impacts on FDNY Rescue Workers 6
In the aftermath of 9/11, the health consequences to our FDNY members (Fire and EMS) were both immediate and far-reaching. In the hours after the collapses, members fought to survive while working to find lost coworkers and 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, emergency

medical 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 Services

World Trade Center 

7

Dr. 

Dr

Dr. Kerry Kelly Dr. David Prezant 

Chief Medical Officer, BHS Chief Medical Officer, OMA 
8

Letter from Firefighting Unions

World Trade Center Health Impacts on FDNY Rescue Workers

Dear UFA and UFOA Members:Words cannot capture our experiences on 9/11/01 and in the days, wee

343 of our Brothers. We do not want to lose one more. Most of us--soWTC site, the Fresh Kills landfill or the Medical Examiner’s office. Althouwe experienced, we can improve our health through medical monitorin

Within a month of the 9/11 attacks, BHS initiated comprehensive medical screenings fBHS in designing the FDNY BHS World Trade Center Medical Monitoring and Treatmenbers. Your periodic annual medical is the World Trade Center medical for those Fi9/11/01. Together--the City, FDNY, BHS, IAFF, UFA and UFOA and our fellow unionfrom the United States Congress for long-term medical and mental health monitoring We urge all members exposed on 9/11 and in the aftermath to participate in the FDNMonitoring and Treatment Program. The program has been expanded to include treatmThe program includes diagnostic testing, outside counseling referrals and free medi

BHS continues to schedule active and retired members for repeat, follow-up exams evThis book on the medical and mental health impacts of 9/11 provides valuable informber, their families and their health care providers. We strongly recommend that you thomation. If you have questions after reading the book, please bring them to your healtWTC diagnosis and treatment guidelines to your personal physician. We are grateful to BHS for its insight, vision and dedication to protecting our membeserve as active and voting members on the World Trade Center Medical MonitorinCommittee. We look forward to our continued collaborative efforts. We thank our mWe wish you all the very best health--today, tomorrow and in the future.Sincerely,Stephen J. Cassidy John J. McDonnell

UFA, Local 94 UFOA, Local 854

Stephen J. Cassidy 

John J. McDonnell
9

Letter from EMS Unions

Dear EMS Members:Your heroic actions on 9/11/01 and your dedication in the months that followed will never be forgotten. We also 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 and free 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 SOA

World Trade Center 

Patrick B

Mark S

Thomas 
W 10 orld Trade Center Health Impacts on FDNY Rescue Workers

FDNY Ceremonial Unit member at th

World Trade Cent
SE

INTRODUCTION & T

History of the FD
12 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 1 INTRODUCTION

During the past five years, FDNY’s World Trade Center Medical Monitoring and Treatment Program (FDNY- WTC-MMTP) has become a national model in terms of both providing services for Department members

and 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 the

FDNY-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.MISSION

The current mission of the FDNY WTC Program is to evaluate and treat individual FDNY members, both active and

retired, who worked at thdevelops plans for futuranalyzing patterns of ianswer central questions sure. Monitoring and tresion of what the FDNY Bdoes everyday--improvinperiodic medical evaluatevaluations and treatmenHISTORY OF THE FDN

One month after the 

ance of our Chief MedDavid Prezant, FDNY-Bscreenings. Both doctorunderstood the potential the unique exposures eFDNY rescue workers (FBHS co-designed this propartnering with the UnifoUniformed Fire Officers Association of Fire FightMedical Technicians anOfficers (UEMSO) and (SOA). 

The periodic medica

place for active members WTC Program and enabrapidly. We are proud thidentify and treat WTC-reProgram helped to infincluding those provideWTC Medical MonitorinFDNY responders a
13

SECTION 1 • INTRODUCTION

World Trade Center 

Environmental Health Center’s Treatment Program. 

Recognizing the potential for long-term health consequences

from 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 provide

WTC-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.FUNDING

In October 2001, only four weeks after the attack, FDNYBHS began performing standardized medical screenings on

WTC 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 from

CDC/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 to

provide 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,

1 Hospitals in the Mount Sinai Consortium:

• Mount Sinai School of Medicine/I. J. Selikoff Center for Occupational 

and Environmental Medicine

• Long Island World Trade Center Monitoring and Treatment

Programs/Stony Brook Medical Center

• Center for the Biology of Natural Systems, Queens College• University of Medicine & Dentistry of New Jersey/Robert Wood

Johnson Medical School, Environmental & Occupational HealthSciences Institute

• Bellevue Hospital Center/NYU School of Medicine

including the FDSAMSA and (November 200from the federaused to continutreatment effortssupport the prog

The FDNY co

federal funding long-term monifederal funding ed needs; therFDNY WTC Prog

The FDNY an

ers of this progrfederal governmspent only oCommissioner amental in helpinFDNY WTC Prog

City governm

September 2006to make recommof WTC health “Addressing the sequent testimothe U.S. Senate, to fully support Sinai ConsortiuTreatment PrograBellevue HospitaTreatment Progr
14

WTC AttacksTower 1 and 2 collapse Total job recallBHS sets up triage center onBroadwayTower 7 collapse BHS treats members for WTCsymptoms & injuries CSU 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 site WTC Medicals begin 7 days a week,3 shifts per dayBHS and CDC partnership to test forheavy metals, PCBs and PAHs BHS 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 2

Fires at WTCsuppressed

Dr. Prezant aSenator HillaClinton at joconference to $12 million Dr. Kelly addNY CongressDelegation ohealth effects NY Daily NJan. 20th. “TAttacks Take Toll: PosttrauStress hits FinBravest”

BHS WTC PROGRAM TIME LINE—September 2001

World Trade Center Health Impacts on FDNY Rescue Workers

BHS Programs/ActivityBHS Press ClippingsBHS Published Scientific Articles

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

2001
15 World Trade Center 

NY 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 andLabor

BHS gives testimony at NY Academy ofMedicine Specialists WTC Meeting MMWR, 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”

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

2002

WTC 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 2007
16

NY Daily News,January 24th. “He'llHear from Bravest.They want 9-11 aidfrom Bush at Stateof Union”

JANUARY

Am. J. Resp. Crit.Care Med., February2003. “PersistentHyperreactivity andReactive AirwayDysfunction inFirefighters at theWorld Trade Center”

FEBRUARY

NY Daily News,May 25th. “Sept. 11Horror HauntsHeroes: physical,mental trauma surfacing”

MAY

First anniversary ofTobacco CessationProgram--more than600 members andfamilies treated witha 50% success rate

JULY

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

SEPTEMBER

October 15thBioPOD exersuccessfully cedRetired membwelcomed baWTC follow-uicalsDr. Weiden teon WTC Heafirst respondeCongress

OCTOBER

2003

World Trade Center Health Impacts on FDNY Rescue Workers

BHS Programs/ActivityBHS Press ClippingsBHS Published Scientific Articles

BHS WTC PROGRAM TIME LINE—September 2001
17 World Trade Center 

Second BHS9/11BehavioralHealthScreen sentto UFOAmembersand UFAretirees

SmallpoxVaccinationProgrambegins forhealth careworkers andfirst responders

NY DailyNews, May24th. “1,700Sue Over 9-11 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

NOVEMBER

American 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-BHbeginsEnhancedWTCMedicalMonitorinVersion 2BHS begincreasinstaff size enhancedmedicals

2004 2

$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
18 World Trade Center Health Impacts on FDNY Rescue Workers

FDNY 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”

JANUARY

Dr. Kelly and Dr. Prezant testify beforeCongress for WTC treatment dollarsRetiree WTC MedicalMonitoring Program officially beginsNY Daily News, Feb.19th. “Clear the Air on9-11 Health”

FEBRUARY

BHS 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”

MARCH

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

APRIL

NY Times, May 2nd“‘Teachable’ 9/11Moment Helped SmoQuit”NY Post, May 15th.“Heroes’ Breath toll--9/11 Sucks 12 Yearsfrom Bravest Lungs”NY Times, May 16t“Firefighters’ LungCapacity Suffered afte9/11 Work, Study shoabout 10 times usualloss”NY Post, May 22nd“Medics Kids MostShaken After 9/11”

MAY

2006

BHS Programs/ActivityBHS Press ClippingsBHS Published Scientific Articles

BHS WTC PROGRAM TIME LINE—September 2001
19 World Trade Center 

Dr. 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”

JULY

More 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”

AUGUST

5th 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

SEPTEMBER

FDNY receives$20 millionsupplementfrom NIOSH tobegin free medication programand expandtreatment

NOVEMBER

BHS beginsWTC treatmentwith free medications

DECEMBER

2006 & 2007

BHS WTC PROGRAM TIME LINE—September 2001-April 2007
20

Aerial view of Ground Zero during recovery operations p

World Trade Center Health Impacts on FDNY Rescue Workers
SE

M

EXPOSURE ASSE

Medical Q

Arriva

Mask/

Eye and Skin Irrita

Respiratory Symptoms for Different Exp

Lower Respirat

Upper Respirat

Scie

Pulmonary Function Loss (by 

Pulmonary Function Loss by Work Assignmen

Methacholine Challenge Testing Hyperre

Dise

“Sarcoid-Like” Granulomatou
22 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 MEDICAL AND EXPOSURE AS

On 9/11/01, BHS physicians immediately responded to the WTC. They were present during 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, including

complete 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 included

a 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

challenges, stress recog

To assess the long-t

cal impacts of 9/11 on the WTC Program devecomputerized questionmedical interviewing aretirees. The initial quOctober 2001 to Octowith an updated que2002 until August 200responding was 9953 14,200 cumulatively afuture, we will strive to all 16,200 members w

Responses have bee

to August 2005 periosimilar data from Augusions of the computerizunprecedented responbers’ recognition of tProgram and their actimembers will continue we gain helps us to deour members’ needs. Tas shown on the follWTC-related symptommental health) are strosite. The information contained in Section 2 has been gathered from medical questionnaires taken by active and retired FDNY members at the FDNY Bureau of Health Services during medical monitor- ing evaluations administered post-WTC. Active FDNY members were asked to respond to the questionnaire at their periodic company medical, which now includes the WTC medical.
23

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

World Trade Center 

In an effort to better understand the health effects of Ground Zero exposure on

FDNY employees, we classified rescue workers into four groups, based on their

estimated arrival times at the WTC site.1

➤ Arrival 

rescue wthe morncollapse

➤ Arrival 

rescue wthe WTC Day 1 o

➤ Arrival 

rescue wthe WTC 

➤ Unexpo

rescue wanytime, 

Ninety-nine percent of the group surveyed responded to the WTC. There was a job-wide recall that brought in active

members. 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. 1 Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.

ARRIVAL TIME AT WTC

FDNY

Rescue

Workers

16,00014,00012,00010,000

8000600040002000

0

Total Deceased Arrival

Group I

Arrival

Group II

Arrival

Group III

Unexposed

Group

343

2.5%

13,854

9435

68.1%

1858

13.4%

2031

14.7%

187

1.3%
24 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

* A respirator is a specially fitted device worn over the mouth and/or nose that pro2Data analysis collected from questionnaires completed by FDNY rescue workers O

Frequency of mask and/or respirator* use is a promin

when determining the severity of the exposur

by WTC rescue workers.2

When the towers collapsed, an enormous dust cloud with a high concentratio

lower Manhattan. FDNY first responders constantly inhaled this thick air, a proceand open-mouth breathing. On Day 1, even those with self-contained breathing apfor about 15 minutes. After the SCBAs ran out of air and for the many who did nrespirators available to rescue workers and those who used protection wore dust marect for biological emergencies; however, dust, surgical masks and N95 “TB” respirpiratory protection at a collapse/fire disaster site. The correct mask for this exposuly available until after the first week. The intense environmental exposure is directtoms/illnesses described throughout this publication.

Day 1➤ 56% never wore a mask/respirator➤ 23% rarely wore a mask/respirator➤ 21% mostly wore a mask/respirator

Day 2

➤ 47% never worn➤ 23% rarely worn➤ 30% mostly worn

Weeks 2-4

➤ 12% never worn➤ 19% rarely worn➤ 69% mostly worn

After Oct. 1, 2001

➤ 9% never worn➤ 16% rarely worn➤ 75% mostly worn

MASK/RESPIRATOR USE

100

80604020

0

Day 1 Day 2 Wk. 2-4 

FDNYWTCRescueWorkers(%)
25

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

World Trade Center 

The number of rescue workers suffering from eye and skin irritation has

decreased dramatically as time has progressed.3

One Mont➤ 70% of 

eye irrita

➤ 30% had 

One Year 

➤ 47% had ➤ 25% had 

Years 2-4 

➤ 7% had ➤ 4% had 

Eye and skin irritations were likely to occur when exposed to the thick dust cloud, as evidenced by the high

rates 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.

FDNYWTCRescueWorkers(%)

Post-WTC mo. 1Post-WTC yr. 1Post-WTC yrs. 2-4

Eye Irritation Skin Irritation

8070605040302010

0

EYE AND SKIN IRRITATION POST-WTC
26 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

4Data analysis collected from questionnaires completed by FDNY rescue workers 

The incidence of respiratory symptoms in the first 

is directly related to WTC arrival tim

In total, more than 79 percent of those present during the morning of 9/11/01 

symptom, with a large number demonstrating multiple symptoms. Our data show exposure and respiratory ailments. These data clearly indicate that earlier arrival hours) at WTC by FDNY members are associated with the highest incidence rate foentific groups have mirrored our results, showing a clear association between arrival t

Daily Cough➤ 54% of Arrival Group I➤ 47% of Arrival Group II➤ 31% of Arrival Group III

Shortness of Breath

➤ 38% of Arrival Group I➤ 25% of Arrival Group II➤ 14% of Arrival Group III

Wheezing

➤ 27% of Arrival Group I➤ 20% of Arrival Group II➤ 12% of Arrival Group III

Chest Pain

➤ 30% of Arrival Group I➤ 20% of Arrival Group II➤ 10% of Arrival Group III

Any of these Symptoms

➤ 79% of Arrival Group I➤ 69% of Arrival Group II➤ 50% of Arrival Group III

100

80604020

0

Daily Cough Short of Breath Wheeze Chest 

Arrival Time Exposure Category

Group I=AM of 9/11/01

Group II=Next 36 hours (Day 1 PM & D

Group III=After Day 2

FDNYWTCRescueWorkers(%)

RESPIRATORY SYMPTOMS FOR DIFFERENT EXPO

YEAR 1

Arrival Group IArrival Group IIArrival Group III
27

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

World Trade Center 

With early diagnosis and treatment, the incidence rate of lower respiratory

symptoms has declined significantly since 9/11/01, but these symptoms persist

in many of our members.5

Day 1 9/1➤ 99% of 

ent were 

➤ 43% had ➤ 30% we➤ 36% had 

Month 1 P

➤ 53% had ➤ 29% had ➤ 21% we➤ 24% had 

Year 1 Po

➤ 46% had ➤ 25% had ➤ 20% we➤ 20% had 

Years 2-4 

➤ 31% had ➤ 28% had ➤ 20% we➤ 11% had 

Day 1 exposure to clouds of dust and debris resulted in cough symptoms for 99% of those present at the WTC

site. 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 SYMPTOMS

100

80604020

0

Daily Cough Short of Breath Wheeze Chest Pain

FDNYWTCRescueWorkers(%)

Pre-WTCWTC 9/11Post-WTC mo. 1Post-WTC yr. 1Post-WTC yrs. 2-4
28 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 • MEDICAL QUESTIONNAIRE DATA

6Data analysis collected from questionnaires completed by FDNY rescue worker

Upper respiratory symptoms were the most common 

by FDNY rescue workers, but these symptoms, while pe

also shown great improvement over 

Upper respiratory symptoms (cough, nasal/sinus congestion/drip, sore/hoarse 

evolution during the four years following 9/11/01. On Day 1, more than half of the above symptoms. One year later, more than half of our rescue workers were stiltoms and 2-4 years later, about 25% were still struggling with daily or frequent symhas shown a highly alkaline pH of WTC dust (like lye), which is extremely irritating 

Day 1 9/11/01➤ 99% of FDNY rescue workers 

present were coughing

➤ 80% had nasal congestion➤ 63% had sore/hoarse throat

Month 1 Post-WTC

➤ 53% had a daily cough➤ 40% had frequent nasal congestion➤ 54% had frequent sore throat

Year 1 Post-WTC

➤ 46% had a daily cough➤ 25% had frequent nasal congestion➤ 46% had frequent sore throat

Years 2-4 Post-WTC

➤ 31% had a daily cough➤ 32% had frequent nasal congestion➤ 22% had frequent sore throat

UPPER RESPIRATORY SYMPTOMS

100

80604020

0

Daily Cough Frequent Nasal/Sinus 

Congestion/Drip

FDNYWTCRescueWorkers(%)
29

SECTION 2 • SCIENTIFIC TEST RESULTS

World Trade Center 

Although loss of lung function can be linked directly to arrival time, all exposure

groups experienced an unprecedented decline in lung function within the 

first 12 months following the WTC attacks.7

Pre-WTC➤ On aver

lose 31 year (simages)

Within the 

➤ Member

ml of FE12 times annual l

➤ Member

372 ml times the loss)

➤ Member

357 ml than 11 annual l

Since 1997, FDNY rescue workers have participated in a periodic medical evaluation (every 12 to 15

months) 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-WTC 

0

-50

-100-150-200-250-300-350-400-450-500

PULMONARY FUNCTION LOSS: 

FIRST YEAR AFTER 09/11/2001

BY ARRIVAL TIME EXPOSURE CATEGORY

-388 -372

-357

-31 -31 -31

Arrival

Group I

Arrival

Group II

Arrival

Group III

Arrival Time Exposure Category

Group I = AM of 9/11/01;

Group II = Next 36 hours (Day 1 PM & Day 2); Group III = After Day 2
30 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 • SCIENTIFIC TEST RESULTS

8Data analysis collected from PFTs by FDNY rescue workers Jan. 1996-Sept. 20

When we break down our rescue workers into two gro

greater average decline in pulmonary function than E

groups still had greater average declines than 

The greater decline of FEV1 in Firefighters compared to EMS workers likely is 

job in the rescue and recovery effort. Fire suppression and search activities kept ing debris and pulverized rubble. Although EMS workers have lost less lung funcage, they still showed a substantial decline in lung function, indicating WTC envirrelated tasks performed and perhaps proximity to the Ground Zero site played r

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 FEV1

on average (more than 10 times theaverage pre-WTC annual loss)

➤ Firefighters lost 384 ml of FEV1 on

average (more than 12 times theaverage pre-WTC annual loss)

➤ Firefighters had 20% greater decline

in FEV1 than EMS employees

PULMONARY FUNCTION LOSS: FIRST YEAR AFT

BY WORK ASSIGNMENT (FIRE & EM

0

-50

-100-150-200-250-300-350-400-450-500

Ad

j

u

s

t

e

d

F

E

V

1

L

o

s

s

(

m

l

)

-31 -31

-320

-384

EMS FIRE
31

SECTION 2 • SCIENTIFIC TEST RESULTS

World Trade Center 

The Methacholine Challenge Test (MCT) is a specialized, objective test used

to confirm the diagnosis of asthma in symptomatic FDNY rescue workers

who have normal pulmonary function.9

1 Month P➤ 24.7% o

Airway H

➤ 8% of m➤ 3.6% of 

3 Month P

➤ 23.8% o

AHR

➤ 6.8% of ➤ 3.6% of 

6 Month P

➤ 27.6% o

AHR

➤ 8.3% of 

Methacholine is a chemical that when inhaled at increasing doses in a controlled setting, identifies who is likely ➤ 3.6% of 

to 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.

PercentHyperreactive

Arrival Group IArrival Group IIUnexposed Group

1 Month 3 Month 6 Month Control

3025201510

50

METHACHOLINE CHALLENGE TESTING

HYPERREACTIVE SUBJECTS (PC20 <8)

n=19/77 n=19/80

n=2/25

n=3/44

n=3/36

n=1/28

n=21/76
32 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 2 • DISEASE SURVEILLANCE

10Data analysis collected from medical charts of FDNY rescue workers Jan. 198

OTHER RESPIRATORY DISEASES EMERGING AFTER 9/11/

sarcoidosis or WTC sarcoid-like granulomatous pulmon

increased markedly in the first year post

Sarcoidosis is an inflammatory disease producing tiny lumps of cells (granuloma

lungs, lymph nodes and skin, all of which are entry points for occupational and eis unclear, but sarcoidosis is associated with exposures to organic and chemical duor smoke. Compared to population values, FDNY-BHS showed increased incFirefighters during the 15 years pre-WTC, presumably due to smoke exposure. AftFDNY sarcoidosis cases increased dramatically, especially in the first year post-WTnew cases are symptomatic (69%) with shortness of breath, cough and other asthcases primarily involve the lung, it may be more accurate to classify them as WTpulmonary disease (SLGPD). Other rare pulmonary diseases in FDNY rescue eosinophilic pneumonitis (occurring in 2002 and cured with early diagnosis and tfibrosis (1 fatality in 2004 and 1 who may need a lung transplant).

15 Years Pre-WTC➤ 0 to 5 FDNY rescue workers contract

sarcoidosis annually, an averageincidence rate of 13/100,000.Most were asymptomatic

9/11/01-9/11/02

➤ 13 new cases develop in FDNY rescue workers, an 86/100,000 annual

incidence rate (or more than a 6-foldincrease from pre-WTC levels)

9/11/02-9/11/06

➤ 13 new cases of sarcoidosis develop

in the next four years, an averageannual incidence rate of22/100,000

Asthma

➤ 69% of those diagnosed with sarcoidosis since 9/11/01 had new

onset asthma

Airway Hyperreactivity (AHR)

➤ 8 of 21 (38%) of sarcoidosis patients

who take a challenge test have AHR

141210

86420

N

u

m

b

e

r

o

f

P

a

t

i

e

n

t

s

“SARCOID-LIKE” GRANULOMATOUS PNEU

FDNY: PRE- & POST-WTC

1985 1987 1989 1991 1993 1995 1997 1999
SE

MENTAL 

ASSE

Mental Health Q

FDNY WTC Survivors Closely Linked to Those L

WTC-Related Health Concerns 

WTC-Related Concerns About Early Mortality 

Change in Sleep-Related Is

Change in M

Feelings of Distance and Detachm

Reliving and Remembering the W

Change in Exercise Prog
34

FDNY members and trades personnel work at Ground Z

World Trade Center Health Impacts on FDNY Rescue Workers
35 World T

MENTAL HEALTH ASSESSMENT SE

For more than 25 years, the FDNY Counseling Service Unit (FDNY-CSU) has been meeting the needs of the FDNY community. Prior to 9/11/01, it provided coun- seling for family issues, personal stress or when an

FDNY 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 WTC

Program 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 to

increase 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 about

arrival 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 the

number 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 emotional

impact 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 ical effecing self-rnaires.
36 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 3 • MENTAL HEALTH ASSESSMENT

1 Data analysis collected from questionnaires completed by FDNY rescue worker

The majority of FDNY members reported close 

lost at the WTC site.1

An overwhelming 98% of FDNY rescue workers knew at least one person who 

more than one person. In addition to being members of the FDNY extended famthat tragic day held multiple, diverse roles as spouses, fiancés, significant others, coworkers. The close bonds formed between those members who sacrificed their to explain the extent of our members’ suffering in the aftermath of 9/11. Despimembers dedicated themselves to continuing the search for the missing. Each pected reports of new identifications can serve to rekindle these emotions.

➤ 98% of FDNY rescue workers lost

someone they knew on 9/11/01

➤ 68% lost FDNY close friends➤ 52% lost FDNY acquaintances➤ 7% lost FDNY relatives➤ 23% lost non-FDNY relatives and

close friends

FDNY WTC SURVIVORS CLOSELY LINKED TO THOSE LO

100

80604020

0

F

D

N

Y

WT

C

R

e

s

c

u

e

W

o

r

k

e

rs

%

Knew someone FDNY Close

Friends

FDNY

Acquaintances

F

Re

98

68

52
37

SECTION 3 • MENTAL HEALTH ASSESSMENT

World Trade Center 

Early responders expressed the greatest health 

concerns after working at the WTC site.2

Year 1 Post-WTC➤ All FDNY Rescue Workers 93% had WTC-related health concerns➤ Arrival Group I 95% had health concerns➤ Arrival Group II 94% had health concerns➤ Arrival Group III 85% had health concerns

WTC-related health concerns are seen in all response groups, regardless of

arrival 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 by

FDNY rescue workers Oct. 2001-Oct. 2002.

FDNY

Any Arrival Time

Arrival Group I Arrival Group II Arrival Group III

100

80604020

0

WTC-RELATED HEALTH CONCERNS

BY ARRIVAL TIME

Arrival Time Exposure Category 

Group I = AM of 9/11/01; Group II = Next 36 hours (Day 1 PM & Day 2);

Group III = After Day 2

93 95 94 85

FDNY WTC Rescue Workers (%)

Concerns about early mortality 

workers are strongly correlated 

WTC-RELATED CONCERN

MORTALITY BY ARR

100

80604020

0

Rescue Workers (%)

FDNY

Any Arrival Time

Arrival Group I Arr

Arrival Time Exposure C

Group I = AM of 9/11/01; Group II = Next 3

Group III = After Da

22 31 

In the mental health questionnaire, 22% of FD

they were “feeling as if (their) future will be cut shoillnesses. These results are not surprising, as those ing the collapse of the towers personally experiencthe sudden loss of coworkers and inhaled the mosarrival time, all FDNY rescue workers suffered varyin proximity to those who perished. Concerns aborescue workers are to be expected. As can be seen exposures and concerns translate into high rates grief reactions, post-traumatic stress disorder (PTS

Years 2-4 Post-WTC➤ All FDNY Rescue Workers 22% had ➤ Arrival Group I 31% had early morta➤ Arrival Group II 22% had early morta➤ Arrival Group III 14% had early mort

3Data analysis collected from questionnaires completed b

Oct. 2002-Aug. 2005.
38 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 3 • MENTAL HEALTH ASSESSMENT

FDNY rescue workers self-reported numerous sleep iss

years after working at the WTC site.4

Sleep disturbances were prominent in the first year after 9/11/01 and persiste

could be related to changes in mood and anxiety after the WTC attacks, nightmarworking at the WTC or changes in exercise patterns. Our results indicate that althousymptoms persist. 

4Data analysis collected from questionnaires completed by FDNY rescue worker

FDNYWTCRescueWorkers(%)

Any SleepRelated Issue Difficulty Sleeping Difficulty Getting Good

Night’s Sleep

Nightma

100

80604020

0

CHANGE IN SLEEP-RELATED ISSUES AFTER 

61 58

33 34

46

39

27 22

Year 1 Post-WTC➤ 61% of all FDNY WTC rescue workers reported having sleep-related

problems

➤ 33% had trouble sleeping➤ 46% had trouble getting a good

night’s sleep

➤ 27% had nightmares➤ 14% had difficulty getting out of bed

Years 2-4 Post-WTC

➤ 58% had sleep-related problems➤ 34% had difficulty sleeping➤ 39% had trouble getting a good

night’s sleep

➤ 22% had nightmares➤ 13% had difficulty getting out of bed
39

SECTION 3 • MENTAL HEALTH ASSESSMENT

World Trade Center 

Mood changes that occurred after working at the WTC have endured for

more than 4 years.5

Self-reported persistent changes in concentration, irritability and anger are widespread, with more than

half 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.)

FDNYWTCRescueWorkers(%)Post-WTC yr. 1

Post-WTC yrs. 2-4

Any Mood

Issue

Difficulty

Concentrating

Unusually

Irritable

Unusual

Anger

Unusually

Anxious

100

80604020

0

CHANGE IN MOOD AFTER WTC

58

53

32 32 35 35

23

32

27 29

Year 1 P➤ 58% o

worke

➤ 32% h➤ 35% w➤ 23% h➤ 32% w

Years 2

➤ 53% r➤ 32% h➤ 35% w➤ 27% h➤ 29% w

5Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.
40 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 3 • MENTAL HEALTH ASSESSMENT

Many WTC rescue workers continue to feel di

detached after 9/11/01.6

Many members showed persistent behavioral changes and complex emotiona

stress-induced response to the disaster. Feeling numb, distant or detached are freqing from PTSD, a psychiatric disorder that occurs after exposure to a terrifying event ioccurred or was threatened (as in the case of the WTC attacks). PTSD may occur iand may persist. Effective treatment strategies involving social support, counseling aable at FDNY-CSU. It is unclear why some people are more prone to developinprocess likely involves complex genetic, physical and social factors that are unique 

6Data analysis collected from questionnaires completed by FDNY rescue workers O

FDNYWTCRescueWorkers(%)

Any

Psychological

Issue

Feel

Numb

Feel Distant

from

Family/Friends

Feel Dist

from Oth

100

80604020

0

FEELINGS OF DISTANCE AND DETACHMENT 

60

53

19

10

20 20 21 22 

Year 1 Post-WTC➤ 60% of FDNY rescue workers report

psychological issues (including reexperience issues)

➤ 19% felt numb➤ 20% felt distant from friends or family➤ 21% felt distant from others➤ 17% felt detached from 

surroundings

Years 2-4 Post-WTC

➤ 53% report psychological issues

(including re-experience issues)

➤ 10% felt numb➤ 20% felt distant from friends 

or family

➤ 22% felt distant from others➤ 13% felt detached from 

surroundings
41

SECTION 3 • MENTAL HEALTH ASSESSMENT

World Trade Center 

Year 1 Po➤ 60% of 

psycholodetachm

➤ 29% had ➤ 15% avo

ciated w

➤ 9% had 

WTC 

Years 2-4 

➤ 53% rep

(includin

➤ 29% had ➤ 15% avo

ciated w

➤ 15% had 

WTC 

➤ 11% had 

memorie

➤ 20% had 

7Data analysis collected from questionnaires completed by FDNY rescue workers Oct. 2001-Aug. 2005.

Nearly 30% of FDNY rescue workers continue to have flashbacks 

from the WTC experience.7

With 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 WTC

memories 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.”

FDNYWTCRescueWorkers(%)

Post-WTC yr. 1Post-WTC yrs. 2-4

Any Psychological

Issue

Flashback

Memories of

WTC

Avoiding WTC

Things/People

Difficulty

Remembering

WTC

Physical

Reaction to

WTC

Memories

Guilt

Feelings

about WTC

100

80604020

0

RELIVING AND REMEMBERING THE WTC EXPERIENCE

60

53

29 29

15 15

9

15

11

20
42 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 3 • MENTAL HEALTH ASSESSMENT

8Data analysis collected from questionnaires completed by FDNY rescue worker

In the first year after 9/11/01, the majority of our memb

they did before the WTC attacks. However, these trend

variety of reasons.8

Given the physical demands of the job, we always expect to find most FDNY re

an active lifestyle. As our members are aware, exercise provides an excellent oHowever, in the first year following the WTC attacks, exercise routines were decrethe FDNY rescue workers. This may have complicated the ability to handle stress. Tbetween year 1 and years 2-4 reflects increased time available for exercise and, state of health (physical and mental) of our rescue workers.

Year 1 Post-WTC➤ 66% of FDNY rescue workers

reported a change in exercise program post-WTC

➤ 37% exercised less due to lack of

time

➤ 23% exercised less because they

did not feel like it

➤ 5% exercised more

Years 2-4 Post-WTC

➤ 46% reported no change in exercise compared to pre-WTC routine➤ 13% exercised less due to lack of

time

➤ 15% exercised less because they

did not feel like it

➤ 18% exercised more

FDNYWTCRescueWorkers(%)

PoPo

Change in routine Decreased due 

to lack of time

Decreased

because do not 

feel like it

100

908070605040302010

0

CHANGE IN EXERCISE PROGRAM AFTER W

66

46

37

13

23

15
SE

FDNY RETI

AND DISABILIT

FDNY Retirements an

Disability P

Number of Pulmonary Cases Und

Number of Permanent Psychological Im

Number of Cardiac Cases Und

Number 

NYCERS EMS “3/4” Disability Pension Applica
44

343 flag-bearing FDNY members proudly march up 5th AMetropolitan Museum of Art in the March 17, 2002, St. P

World Trade Center Health Impacts on FDNY Rescue Workers
45 World T

SE

The traumatic ephysical and meresulted in an unretirements in thas an increasegranted by the F

FDNY RETIREMENT AND DISABILITY DATA

In years pre-9/11 (9/11/99 to 9/10/01), there was an average of 544 annual Firefighter retirements. In the first two years post-WTC, 1216 and 1201 Firefighters 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 severely

affected 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 unprecedented 

number of FDNY Firefighter retirements. 

FDNY Retirements and Years of Service

DATE EMS FIRE FIRE (>20 YRS.) FIRE (>20 YRS.)

Percent

9/11/99 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 51
46 World Trade Center Health Impacts on FDNY Rescue Workers 1Data analysis collected from FDNY Fire pension records.

The persistent increase in disability pensions granted 

Lung Bill reflects WTC exposure and related dise

Due to the nature of the profession, Firefighters inevitably are exposed to smo

severe respiratory problems. Long before the WTC attacks, Firefighters have had pension system when lung problems interfered with occupational demands. The pognize the hazards of firefighting, with its recurrent exposures despite protective geavides disability pensions only after a rigorous, objective evaluation of pulmonary funoted above after 2001 is strongly tied to the WTC-related respiratory symptoms adescribed previously. From 2002 to 2006, 728 members qualified for permanenLung Bill. 

NUMBER OF PULMONARY CASES RECEIVING FD

DISABILITY PENSION (“3/4”) UNDER THE LUNG 

# of Cases

250200150100

50

0

1999 2000 2001 2002 2003 2004 200

Year

45 58 44

135

153

181

132

SECTION 4 • FDNY RETIREMENT AND DISABILITY DATA

Pre-WTC

➤ An average of 49 FDNY Firefighters

and Fire Officers collect disabilitypensions for lung problems annually

Post-WTC

➤ An average of 146 FDNY

Firefighters and Fire Officers collectdisability pensions for lung problemsannually
47

SECTION 4 • FDNY RETIREMENT AND DISABILITY DATA

World Trade Center 

Pre-WTC➤ No cases 

impairmen

Post-WTC

➤ An averag

psychologreceive dis

2 Data analysis collected from FDNY Fire pension records.

In this resilient population, certain members developed permanent 

psychological impairments and were granted service-connected 

disability pensions for these problems.2

With rare exceptions, FDNY did not provide disability pensions for stress-related cases until after the

events 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 PSYCHOLOGICAL 

IMPAIRMENT CASES RECEIVING DISABILITY PENSION (“3/4”)

# of Cases

25201510

50

1999 2000 2001 2002 2003 2004 2005 2006

Year

0 0 0

20

16

Pre-WTCPost-WTC 

16

20

3
48 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 4 • FDNY RETIREMENT AND DISABILITY DATA

Following the WTC attacks, the average number of card

FDNY disability pension under the Heart Bill has remai

there were spikes in years 2002 and 2

that we are studying more closely.3

Under the provisions of the Heart Bill, FDNY disability pensions are granted on

Members with other cardiac illness, such as cardiomyopathy and cardiac rhythm punder the provisions of the Heart Bill. WTC monitoring will continue to evaluate mcardiac health after this exposure. At periodic medical evaluations, FDNY-BHS conify cardiac risk factors (obesity, sedentary lifestyles, elevated cholesterol levels, smoa spike in numbers, with a return to pre-WTC levels in 2003-2004. Members with have deferred retirement for one year to help with the rescue and recovery effort pin 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 DISA

PENSION (“3/4”) UNDER THE HEART BILL

# of Cases

5040302010

0

1999 2000 2001 2002 2003 2004 200

Year

23 23

29

12

22 20

39

Pre-WTC➤ An average of 25 FDNY Firefighters

and Fire Officers collect disabilitypensions for cardiac problemsannually

Post-WTC

➤ An average of 26 FDNY Firefighters

and Fire Officers collect disabilitypensions for cardiac problemsannually
49

World Trade Center 

Pre-WTC➤ An avera

and Fire pensions 

Post-WTC

➤ An avera

and Fire pensions 

➤ In 2006

15 caseretirees 

The Cancer Bill (1994) is a presumptive bill that was enacted in

recognition 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 retiring

due 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 retired

members, 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 DATA

4Data analysis collected from FDNY Fire pension records.

FDNY-BHS is closely monitoring late onset diseases, such as cancers, to look

for emerging patterns post-WTC.4

NUMBER OF CANCER CASES RECEIVING 

FDNY DISABILITY PENSION (“3/4”) 

# of Cases

353025201510

50

1999 2000 2001 2002 2003 2004 2005 2006

15

16 15

10

19 19 20

WTC Bill--RetireesCancer Bill Post-9/11Cancer Bill Pre-9/11

12

15

WTC

Disability Bill--

newly eligible

retirees
50 World Trade Center Health Impacts on FDNY Rescue Workers

EMS personnel collect disability pensions through New York City Employees’ Re

Like the FDNY system for Firefighters, disability pensions for EMS personnel are aobjective health evaluations have been reviewed by an independent board. The ninclude disability pensions collected for respiratory ailments, permanent psycholabling cancers, as well as pensions collected under the Heart Bill and, beginning to 2006, disability pensions from WTC-related injuries and illnesses were not dcauses. Between 1/1/06 and 7/30/07, 9 EMS personnel were granted pensions ucould not provide us with diagnoses due to confidentiality issues, but of these 9 cnosed 4 with asthma, 2 with sarcoidosis, 1 with cancer, 1 with PTSD and 1 with b

NYCERS EMS “3/4” DISABILITY PENSION 

APPLICATIONS APPROVED

# of Cases

353025201510

50

2000 2001 2002 2003 2004 2005 

Year

21

19

24 

Pre-9/11Post-9/11 29

23

24

Pre-WTC➤ An average of 20 EMS personnel

collect “3/4” disability pensionsannually

Post-WTC

➤ An average of 25 EMS personnel

collect “3/4” disability pensionsannually. 9 EMS personnel collect“3/4” disability pensions under theWTC Bill

SECTION 4 • NYCERS EMS RETIREMENT AND DISABILITY D
SE

THE FDNY-WORLD TRADE 

MEDICAL MON

TREATMENT PR

POST-

Number of Monitoring 

Annual Number of Patients in the FDNY-WTC Medical Tr

Tobacco Cessat

CSU Provides Counselin

Annual Number of Patients in the FDNY-CSU WTC Mental Health Tr
52

SECTION 5

More than five years after the attack, the FireDepartment’s WTC Program continues itscommitment to providing our members withthe best monitoring and treatment programspossible.

World Trade Center Health Impacts on FDNY Rescue Workers

Monitoring Program Total Enrollment: 14,319 (10/0

To date, 14,319 members participate in the FDNY WTC Program. WTC medica

be provided every 12-18 months to every active member (Fire and EMS) who servis part of the regular periodic company medical. As of April 30, 2007, 10,415 intial monitoring exam and 8687 had received at least one follow-up monitoring exafollow-up monitoring exams began October 5, 2006, and the number of members For the first time in FDNY history, we have included retirees in this post-exposure pafter 9/11/01, more than 1100 retirees participated in the WTC Monitoring and 30, 2007, this has expanded to include 3904 retirees who have received an initiwho have received at least one follow-up monitoring exam (49% retention rate). Tule exams for retirees, we will be starting an intensive phone outreach campaign shosary of the WTC attacks in September 2007. Participation in the monitoring progfree treatment and medication.

NUMBER OF MONITORING EXAMS CONDUCT

16,00014,00012,00010,000

8000600040002000

0

Visit 1 and 2 Base line Visit 2 Follow-Up Visit 3 Follow-Up*

FDNY-WORLD TRADE CENTER MEDICAL MONITORING 

THIS PROGRAM INCLUDES FIRE AND EMS (ACTIVE A

1Data analysis, FDNY rescue workers Oct. 2001-June 2007.

➤ 14,319 members have participated in FDNY-WTC monitoring
53 World Trade Center 

Immediately after 9/11/01, FDNY-BHS started a treatment program for WTC-related conditions. We were the first

to 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, mental

health). 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-9/11/01

THIS PROGRAM INCLUDES FIRE AND EMS (ACTIVE AND RETIRED). 

ANNUAL NUMBER OF PATIENTS IN THE FDNY-WTC

MEDICAL TREATMENT PROGRAM

30002500200015001000

500

0

9/12/01 to

06/30/02

7/1/02 to

06/30/03

7/1/03 to

06/30/04

7/1/04 to

06/30/05

7/1/05 to

06/30/06

7/1/06 to

06/30/07

Note: The above chart counts each patient only once in any given time range.

➤ 6465 m

in the Fgram fo
54 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 5 • THE FDNY-WORLD TRADE CENTER MEDICAL 

TREATMENT PROGRAM POST-9/11/01

Our studies have shown no link between current FDNY-WTC health findin

well-known that tobacco use results in an increased risk for the development oasbestos workers, we felt it was prudent to offer our members a tobacco cessaFDNY” is a free tobacco cessation program that provides counseling, nicotine medications when necessary. More than 600 members (active, retirees and famour program. We are proud to have some of the highest reported tobacco cessconducted on our first participants, 47%, 36% and 33% had stopped smoking tively. This program continues every Wednesday, alternating between FDNY-Bfor contact information.)

Tobacco Cessation Rates➤ 47% of participants remained tobacco-free continuously for 3 months➤ 36% remained tobacco-free for 6

months

➤ 33% remained tobacco-free for 12

months

TOBACCO CESSATION SUCCESS R

Percent

100

908070605040302010

0

3 months 6 months 

36

47

FDNY Tobacco Cessation Program

Due to WTC-related respiratory illness and health co

development, FDNY-BHS and FDNY-CSU started a fr

program. Only 15% of our rescue workers use tobacc

caused 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 Program
55

SECTION 5 • THE FDNY-WORLD TRADE CENTER MEDICAL MONITORING AND

TREATMENT PROGRAM POST-9/11/01

World Trade Center 

Prior to 9/11/01, the FDNY Counseling Services Unit (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 realized

that 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 were

established 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. The

firehouses 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 the

FDNY-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 FDNY

rescue 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 the

deceased, 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 Treatment

Ma

251 Laf

(21

State

For

Bre

Suffo

Oran

Subst

B

Medic

B

Tob

B
56 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 5 • THE FDNY-WORLD TRADE CENTER MENTAL 

PROGRAM POST-9/11/01

Many members who worked at the WTC site post-9/11 initially did not allow the

lost, so mental health problems tended to surface later, once the search slowed process their emotions. Due to the nature of the job, FDNY members form tight-kntomed to self-management of problems or turning to their team members for adviccounselors provide initial support and encourage members to seek professionatrained mental health practitioners (social workers, psychologists and psychiatrists) other organizations. Referrals to private practitioners were made for those clients increase in use of FDNY-CSU counseling services after the first year post-9/11 remembers of the need for more formal, structured counseling. The continued utilizyears that followed indicates that members continue to seek services as they recoments. Between 9/12/01 and 6/30/07, there have been 157,406 visits to FDNY-and family members. Pre-9/11, there were only 600 visits per year to FDNY-CSU. Fare available for those members (Fire and EMS, active and retired) with WTC-relatWTC Medical monitoring exam.

ANNUAL NUMBER OF PATIENTS IN THE FDNY

MENTAL HEALTH TREATMENT PROGRA

This program includes Fire and EMS (active or retired) 

members. Use of FDNY-CSU counseling services increas

9/11/01 and has remained high, demonstratin

for continued services.

12,00010,000

8000600040002000

0

Total NumbFDNY MemFamily

9/12/01 to

06/30/02

7/1/02 to

06/30/03

7/1/03 to

06/30/04

7/1/04 to

06/30/05

7/

06

TOTAL

➤ Pre-WTC CSU visits:

Annually, 500-600 FDNY rescueworkers

➤ Post-WTC CSU visits:

Annually, approximately 2500FDNY rescue workers
SE

CON

Appendix A 

Appendix B Wellness Se
58 World Trade Center Health Impacts on FDNY Rescue Workers

SECTION 6 CONCLUSION

The World Trade Center Medical Monitoring and Treatment Program is committed to monitoring, assessing and treating the

immediate 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 the

health 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 have

allowed 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 o

active and retireddemonstrated an ufunction in the ye2001. Follow-up stmine the extent to wtinued. Given the symptoms, such amay occur as a reimpair our membeSimilarly, PTSD, dcause serious prob

The FDNY WTC 

itoring evaluations and retired FDNY these problems throuations and providprovide the best chma and pulmonarand other late-eme

Treatment optio

including specializeCAT scans, cardiac “Tobacco Free wrenowned tobacco help those memberWe urge our membprogram. Although 

“It’s a no-brainer. If you care about yourself and your family, this is a chance to see about your condition, 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 it to other retirees. The evaluation was very exten- sive, thorough. For retirees with concerns about their future health, they should come down for this medical evaluation for their piece of mind and for their families, too. There may be unknowns popping up or some problems may show accelerated rate, so it’s important to know what is going on. Everyone at BHS treated us professionally and in a caring manner." Lt. Dennis O’Berg
59 World Trade Center 

to 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 of

the 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 to

work as a team in maintaining your health.

This report has presented the information and

data 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. 
60 World Trade Center Health Impacts on FDNY Rescue Workers

APPENDIX A • PUBLICATION LIST 

Acute 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, RespiratoChanges Among NResponding to the WFeldman DM, Baron S, MuKJ, Prezant DJ, published Induced Sputum AsFirefighters Exposed Fireman E, Lerman Y, GOppenheim E, Flash R, MKJ, Prezant DJ, published November 2004; 112:15Bronchial HyperreactInjuries in Rescue/ReTrade Center CollapseAlva R, Santhyadka G, Krapublished in Am. J. Resp. CPulmonary Disease iTrade Center Site. By Blished in Curr. Opin. Pulm“Tobacco Free with Department World TStudy. By Bars MP, BaMouren P, Kelly KJ, Prezan129:979-987.Pulmonary Function Trade Center in the NBy Banauch GI, Hall C, Christodoulou V, ArcentaleAm. J. Resp. Crit. Care MFDNY Crisis Counse9/11 Firefighters, FGreene P, Kane D, Christ John Wiley & Sons Inc., HWorld Trade Center Pulmonary Disease in 

G, Chauko R, Banauch GI, Prezant DJ, published in Ch
61

APPENDIX B • WELLNESS SELF-TESTS AND TIPS

World Trade Center 

We 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 2

times per week)

❏ Frequent acid reflux/regurgitation into mouth 

(at least 2 times per week)

❏ Frequent heartburn/indigestion (at least 2 times per

week)

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 fumes The 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 QUIZ
62

World Trade Center Health Impacts on FDNY Rescue Workers

APPENDIX B • WELLNESS SELF-TESTS AND TIPS

During 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 throuthreatening event? Pleany problems you hav❏ I feel like the terr

again. This feeling 

❏ I have nightmares a❏ I stay away from pl❏ I jump and feel ve

without warning. 

❏ I have a hard time 

people.

❏ I get mad very easi❏ I feel guilty becaus❏ I have trouble sleepDo these symptoms afat home or work?❏ Yes ❏ NoThe checklist above is simply a list of symptoStress Disorder (PTSD)MORE THAN ONE oPTSD. Only a health canose this condition. PFDNY Counseling Serment options are avaiphone numbers can b

PLEASE TAKE THIS PERSONAL HEALTH QUIZ

FDNY-CSU Locations

Manhattan Counseling Unit

251 Lafayette Street, 3rd Fl, NYC 10012

(212) 570-1693 (24-Hour Line)

Staten Island Counseling Unit

1688 Victory Boulevard

Staten Island, NY 10314

(718) 815-4111

Fort Totten Counseling Unit

Fort Totten Building 413A

Bayside, NY 11364

(718) 352-2140

Brentwood Counseling Unit

Liberty Project Center

Suffolk County Community College

Crooked Hill Road,

Brentwood, NY 11717

(631) 851-6888

Orange County Counseling Unit

2279 Goshen Turnpike

Middletown, NY 10941

(845) 695-1029

Substance Abuse Day-Treatment

Program

594 Broadway, Suite 500

(212) 925-6671

FDNY Headquarters

9 MetroTech Center

Brooklyn, NY 11201-3857

(718) 999-1858

(718) 999-0088 (fax)

Medical Monitoring Examinations

FDNY Headquarters

9 MetroTech Center

Brooklyn, NY 11201-3857

(718) 999-1858

(718) 999-0088 (fax)

Tobacco Cessation Program

9 MetroTech Center

Brooklyn, NY 11201-3857

Fort Totten Building 413B

Bayside, NY 11364

(718) 999-1942
63

World Trade Center 

We 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 your

health-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 FDNY

Tobacco Cessation Program at 718-999-1942. 

· Avoid alcohol abuse and drug use.· Avoid occupational or recreational exposures that

are 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 food

group 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 and

avoid 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 may

make you feel better.

· Improve your environment. Small changes around

your home or office help you feel in control.

· Plan your work to make efficient use of your time

and 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 of

stress.

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 HEALINGPROCESS

APPENDIX B • WELLNESS SELF-TESTS AND TIPS

“I think if rest, exerchave been then you amonitoring eases occsymptoms the monitshould be Dr. David P
64

“When you have a Department whose men and womany moment to put their lives on the line, to go to thmeans that you may put yourself in dire peril, I don’t that job. There has to be something beyond money t

William M. FeehanFirst Deputy Fire Commissioner & Former CMade the Supreme Sacrifice on 9/11/01

“I am proud of this Department. But, I am most pFirefighters, Officers, Fire Marshals, Paramedics/EMTed support staff--who so selflessly perform their jobs, to ensure the health and safety of all New Yorkers anCity 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 ddays, but never a boring day on this job. You’ll love A difficult job and God calls you to it and gives you a will be well-done.”

Father Mychal Judge, OFM, FDNY ChaplaiMade the Supreme Sacrifice on 9/11/01

POSTSCRIPT • A SALUTE TO THE RESCUE WORKERS FRO

THE SUPREME SACRIFICE ON 9/11/0

The 9/11 Memorial Waterford Crystal

The 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.

World Trade Center Health Impacts on FDNY Rescue Workers
New York City Fire Department Members

Who Made The Supreme Sacrifice In The Performance of Duty At The World Trade Center September 11, 2001 Manhattan Box 5-5-8087First Deputy Commissioner William M. Feehan

Office of Fire Commissioner 

Chief of Department Peter J. Ganci, Jr., COD

Assistant Chief Gerard A. Barbara, OperationsAssistant Chief Donald J. Burns, Operations

Deputy Chief Dennis A. Cross, Battalion 57 Deputy Chief Raymond M. Downey, SOC Deputy Chief Edward F. Geraghty, Battalion 9 Department Chaplain Mychal F. Judge, OFM Deputy Chief Charles L. Kasper, SOC Deputy Chief Joseph R. Marchbanks, Jr., Battalion 12 Deputy Chief Orio J. Palmer, Battalion 7 Deputy Chief John M. Paolillo, SOC Battalion Chief James M. Amato, Squad Co. 1 Battalion Chief Thomas P. DeAngelis, Battalion 8 Battalion Chief Dennis L. Devlin, Division 3 Battalion Chief John J. Fanning, Haz-Mat Operations Battalion Chief Thomas J. Farino, Engine Co. 26 Battalion Chief Joseph D. Farrelly, Engine Co. 4 Battalion Chief Joseph Grzelak, Battalion 48 Battalion Chief Thomas T. Haskell, Jr., Ladder Co. 132 Battalion Chief Brian C. Hickey, Rescue Co. 4 Battalion Chief William J. McGovern, Battalion 2 Battalion Chief Louis J. Modafferi, Rescue Co. 5 Battalion Chief John M. Moran, SOCBattalion Chief Richard A. Prunty, Battalion 2 Battalion Chief Matthew L. Ryan, Battalion 4 Battalion Chief Fred C. Scheffold, Battalion 12 Battalion Chief Lawrence T. Stack, Safety Battalion 1 Battalion Chief John P. Williamson, Battalion 6 Captain Daniel J. Brethel, Ladder Co. 24 Captain Patrick J. Brown, Ladder Co. 3 Captain Vincent E. Brunton, Ladder Co. 105 Captain William F. Burke, Jr., Engine Co. 21 Captain Frank J. Callahan, Ladder Co. 35 Captain Martin J. Egan, Jr., Ladder Co. 118 Captain Michael A. Esposito, Squad Co. 1 Captain John R. Fischer, Ladder Co. 20 Captain Vincent F. Giammona, Ladder Co. 5 Captain Terence S. Hatton, Rescue Co. 1 Captain Walter G. Hynes, Ladder Co. 13 Captain Frederick J. Ill, Jr., Ladder Co. 2 Captain William E. McGinn, Squad Co. 18 Captain Thomas C. Moody, Engine Co. 310 Captain Daniel O’Callaghan, Ladder Co. 4 Captain William S. O’Keefe, Engine Co. 154 Captain Vernon A. Richard, Ladder Co. 7 Captain Timothy M. Stackpole, Ladder Co. 103 Captain Patrick J. Waters, Haz-Mat Co. 1 Captain David T. Wooley, Ladder Co. 4 Lieutenant Joseph Agnello, Ladder Co. 118 Lieutenant Brian G. Ahearn, Engine Co. 230 Lieutenant Gregg Atlas, Engine Co. 10 

Lieutenant Steven J. Bates, Engine Co. 235 Lieutenant Carl J. Bedigian, Engine Co. 214 Lieutenant John A. Crisci, Haz-Mat Co. 1 Lieutenant Edward A. D’Atri, Squad Co. 1 Lieutenant Manuel Del Valle, Jr., Engine Co. 5 Lieutenant Andrew J. Desperito, Engine Co. 1 Lieutenant Kevin W. Donnelly, Ladder Co. 3 Lieutenant Kevin C. Dowdell, Rescue Co. 4 Lieutenant Michael N. Fodor, Ladder Co. 21 Lieutenant David J. Fontana, Squad Co. 1 Lieutenant Andrew A. Fredericks, Squad Co. 18 Lieutenant Peter L. Freund, Engine Co. 55 Lieutenant Charles W. Garbarini, Ladder Co. 61 Lieutenant Ronnie E. Gies, Squad Co. 288 Lieutenant John F. Ginley, Engine Co. 40 Lieutenant Geoffrey E. Guja, Engine Co. 82 Lieutenant Joseph P. Gullickson, Ladder Co. 101 Lieutenant David Halderman, Squad Co. 18 Lieutenant Vincent G. Halloran, Ladder Co. 8 Lieutenant Harvey L. Harrell, Rescue Co. 5 Lieutenant Stephen G. Harrell, Ladder Co. 157 Lieutenant Michael K. Healey, Squad Co. 41 Lieutenant Timothy B. Higgins, Squad Co. 252 Lieutenant Anthony M. Jovic, Ladder Co. 34 Lieutenant Thomas R. Kelly, Ladder Co. 105 Lieutenant Ronald T. Kerwin, Squad Co. 288 Lieutenant Joseph G. Leavey, Ladder Co. 15 Lieutenant Michael F. Lynch, Ladder Co. 4 Lieutenant Patrick J. Lyons, Squad Co. 252 Lieutenant Charles J. Margiotta, Ladder Co. 85 Lieutenant Peter C. Martin, Rescue Co. 2 Lieutenant Paul R. Martini, Engine Co. 201 Lieutenant Paul T. Mitchell, Ladder Co. 110 Lieutenant Dennis Mojica, Rescue Co. 1 Lieutenant Raymond E. Murphy, Ladder Co. 16 Lieutenant Robert B. Nagel, Engine Co. 58 Lieutenant John P. Napolitano, Rescue Co. 2 Lieutenant Thomas G. O’Hagan, Engine Co. 52 Lieutenant Glenn C. Perry, Ladder Co. 34 Lieutenant Philip S. Petti, Ladder Co. 148 Lieutenant Kevin J. Pfeifer, Engine Co. 33 Lieutenant Kenneth J. Phelan, Engine Co. 217 Lieutenant Michael T. Quilty, Ladder Co. 11 Lieutenant Robert M. Regan, Ladder Co. 118 Lieutenant Michael T. Russo, Squad Co. 1 Lieutenant Christopher P. Sullivan, Ladder Co. 111 Lieutenant Robert F. Wallace, Engine Co. 205 Lieutenant Jeffrey P. Walz, Ladder Co. 9 Lieutenant Michael P. Warchola, Ladder Co. 5 Lieutenant Glenn E. Wilkinson, Engine Co. 238 Fire Marshal Ronald P. Bucca, Manhattan Base Fire Marshal Andre G. Fletcher, Rescue Co. 5 Fire Marshal Vincent D. Kane, Engine Co. 22 Fire Marshal Kenneth B. Kumpel, Ladder Co. 25 Fire Marshal Paul J. Pansini, Engine Co. 10 Firefighter Eric T. Allen, Squad Co. 18 Firefighter Richard D. Allen, Ladder Co. 15 Firefighter Calixto Anaya, Jr., Engine Co. 4 Firefighter Joseph J. Angelini, Sr., Rescue Co. 1 Firefighter Joseph J. Angelini, Jr., Ladder Co. 4 

Firefighter Faustino Apostol, Jr., Battalion 2 Firefighter David G. Arce, Engine Co. 33 Firefighter Louis Arena, Ladder Co. 5 Firefighter Carl F. Asaro, Battalion 9 Firefighter Gerald T. Atwood, Ladder Co. 21 Firefighter Gerard Baptiste, Ladder Co. 9 Firefighter Matthew E. Barnes, Ladder Co. 25 Firefighter Arthur T. Barry, Ladder Co. 15 Firefighter Stephen E. Belson, Ladder Co. 24 Firefighter John P. Bergin, Rescue Co. 5 Firefighter Paul M. Beyer, Engine Co. 6 Firefighter Peter A. Bielfeld, Ladder Co. 42 Firefighter Brian E. Bilcher, Engine Co. 33 Firefighter Carl V. Bini, Rescue Co. 5 Firefighter Christopher J. Blackwell, Rescue Co. 3 Firefighter Michael L. Bocchino, Battalion 48 Firefighter Frank J. Bonomo, Engine Co. 230 Firefighter Gary R. Box, Squad Co. 1 Firefighter Michael Boyle, Engine Co. 33 Firefighter Kevin H. Bracken, Engine Co. 40 Firefighter Michael E. Brennan, Ladder Co. 4 Firefighter Peter Brennan, Squad Co. 288 Firefighter Andrew C. Brunn, Ladder Co. 5 Firefighter Gregory J. Buck, Engine Co. 201 Firefighter John P. Burnside, Ladder Co. 20 Firefighter Thomas M. Butler, Squad Co. 1 Firefighter Patrick D. Byrne, Ladder Co. 101 Firefighter George C. Cain, Ladder Co. 7 Firefighter Salvatore B. Calabro, Ladder Co. 101 Firefighter Michael F. Cammarata, Ladder Co. 11 Firefighter Brian Cannizzaro, Ladder Co. 101 Firefighter Dennis M. Carey, Haz-Mat Co. 1 Firefighter Michael S. Carlo, Engine Co. 230 Firefighter Michael T. Carroll, Ladder Co. 3 Firefighter Peter J. Carroll, Squad Co. 1 Firefighter Thomas A. Casoria, Engine Co. 22 Firefighter Michael J. Cawley, Ladder Co. 136 Firefighter Vernon P. Cherry, Ladder Co. 118 Firefighter Nicholas P. Chiofalo, Engine Co. 235 Firefighter John G. Chipura, Engine Co. 219 Firefighter Michael J. Clarke, Ladder Co. 2 Firefighter Steven Coakley, Engine Co. 217 Firefighter Tarel Coleman, Squad Co. 252 Firefighter John M. Collins, Ladder Co. 25 Firefighter Robert J. Cordice, Engine Co. 152 Firefighter Ruben D. Correa, Engine Co. 74 Firefighter James R. Coyle, Ladder Co. 3 Firefighter Robert J. Crawford, Safety Battalion 1 Firefighter Thomas P. Cullen, III, Squad Co. 41 Firefighter Robert Curatolo, Ladder Co. 16 Firefighter Michael D. D’Auria, Engine Co. 40 Firefighter Scott M. Davidson, Ladder Co. 118 Firefighter Edward J. Day, Ladder Co. 11 Firefighter Martin N. DeMeo, Haz-Mat Co. 1 Firefighter David P. DeRubbio, Engine Co. 226 Firefighter Gerard P. Dewan, Ladder Co. 3 Firefighter George DiPasquale, Ladder Co. 2 Firefighter Gerard J. Duffy, Ladder Co. 21 Firefighter Michael J. Elferis, Engine Co. 22 Firefighter Francis Esposito, Engine Co. 235 

Firefighter Robert E. Evans, Engine Co. 33 Firefighter Terrence P. Farrell, Rescue Co. 4 Firefighter Lee S. Fehling, Engine Co. 235 Firefighter Alan D. Feinberg, Battalion 9 Firefighter Michael C. Fiore, Rescue Co. 5 Firefighter John J. Florio, Engine Co. 214 Firefighter Thomas J. Foley, Rescue Co. 3 Firefighter Robert J. Foti, Ladder Co. 7 Firefighter Thomas Gambino, Jr., Rescue Co. 3 Firefighter Thomas A. Gardner, Haz-Mat Co. 1 Firefighter Matthew D. Garvey, Squad Co. 1 Firefighter Bruce H. Gary, Engine Co. 40 Firefighter Gary P. Geidel, Rescue Co. 1 Firefighter Denis P. Germain, Ladder Co. 2 Firefighter James A. Giberson, Ladder Co. 35 Firefighter Paul J. Gill, Engine Co. 54 Firefighter Jeffrey J. Giordano, Ladder Co. 3 Firefighter John J. Giordano, Engine Co. 37 Firefighter Keith A. Glascoe, Ladder Co. 21 Firefighter James M. Gray, Ladder Co. 20 Firefighter Jose A. Guadalupe, Engine Co. 54 Firefighter Robert W. Hamilton, Squad Co. 41 Firefighter Sean S. Hanley, Ladder Co. 20 Firefighter Thomas P. Hannafin, Ladder Co. 5 Firefighter Dana R. Hannon, Engine Co. 26 Firefighter Daniel E. Harlin, Ladder Co. 2 Firefighter Timothy S. Haskell, Squad Co. 18 Firefighter Michael H. Haub, Ladder Co. 4 Firefighter John F. Heffernan, Ladder Co. 11 Firefighter Ronnie L. Henderson, Engine Co. 279 Firefighter Joseph P. Henry, Ladder Co. 21 Firefighter William L. Henry, Rescue Co. 1 Firefighter Thomas J. Hetzel, Ladder Co. 13 Firefighter Jonathan R. Hohmann, Haz-Mat Co. 1 Firefighter Thomas P. Holohan, Engine Co. 6 Firefighter Joseph G. Hunter, Squad Co. 288 Firefighter Jonathan L. Ielpi, Squad Co. 288 Firefighter William R. Johnston, Engine Co. 6 Firefighter Andrew B. Jordan, Ladder Co. 132 Firefighter Karl H. Joseph, Engine Co. 207 Firefighter Angel L. Juarbe, Jr., Ladder Co. 12 Firefighter Paul H. Keating, Ladder Co. 5 Firefighter Richard J. Kelly, Jr., Ladder Co. 11 Firefighter Thomas W. Kelly, Ladder Co. 15 Firefighter Thomas J. Kennedy, Ladder Co. 101 Firefighter Michael V. Kiefer, Ladder Co. 132 Firefighter Robert C. King, Jr., Engine Co. 33 Firefighter Scott M. Kopytko, Ladder Co. 15 Firefighter William E. Krukowski, Ladder Co. 21 Firefighter Thomas J. Kuveikis, Squad Co. 252 Firefighter David J. LaForge, Ladder Co. 20 Firefighter William D. Lake, Rescue Co. 2 Firefighter Robert T. Lane, Engine Co. 55 Firefighter Peter J. Langone, Squad Co. 252 Firefighter Scott A. Larsen, Ladder Co. 15 Firefighter Neil J. Leavy, Engine Co. 217 Firefighter Daniel F. Libretti, Rescue Co. 2 Firefighter Robert T. Linnane, Ladder Co. 20 Firefighter Michael F. Lynch, Engine Co. 40 Firefighter Michael J. Lyons, Squad Co. 41 

Firefighter Joseph Maffeo, Ladder Co. 101 Firefighter William J. Mahoney, Rescue CoFirefighter Joseph E. Maloney, Ladder Co. Firefighter Kenneth J. Marino, Rescue Co. Firefighter John D. Marshall, Engine Co. 23 Firefighter Joseph A. Mascali, Rescue Co. Firefighter Keithroy M. Maynard, Engine CoFirefighter Brian G. McAleese, Engine Co. 2Firefighter John K. McAvoy, Ladder Co. 3 Firefighter Thomas J. McCann, Engine Co. Firefighter Dennis P. McHugh, Ladder Co. 1Firefighter Robert D. McMahon, Ladder CoFirefighter Robert W. McPadden, Engine CFirefighter Terence A. McShane, Ladder CoFirefighter Timothy P. McSweeney, Ladder Firefighter Martin E. McWilliams, Engine CoFirefighter Raymond M. Meisenheimer, ResFirefighter Charles R. Mendez, Ladder Co. Firefighter Steve J. Mercado, Engine Co. 40 Firefighter Douglas C. Miller, Rescue Co. 5 Firefighter Henry A. Miller, Jr., Ladder Co. 1Firefighter Robert J. Minara, Ladder Co. 25 Firefighter Thomas Mingione, Ladder Co. 1Firefighter Manuel Mojica, Squad Co. 18 Firefighter Carl E. Molinaro, Ladder Co. 2 Firefighter Michael G. Montesi, Rescue Co. Firefighter Vincent S. Morello, Ladder Co. 3Firefighter Christopher M. Mozzillo, Engine Firefighter Richard T. Muldowney, Jr., LaddeFirefighter Michael D. Mullan, Ladder Co. 1Firefighter Dennis M. Mulligan, Ladder Co. Firefighter Peter A. Nelson, Rescue Co. 4 Firefighter Gerard T. Nevins, Rescue Co. 1 Firefighter Dennis P. O’Berg, Ladder Co. 10Firefighter Douglas E. Oelschlager, Ladder Firefighter Joseph J. Ogren, Ladder Co. 3 Firefighter Samuel P. Oitice, Ladder Co. 4 Firefighter Patrick J. O’Keefe, Rescue Co. 1 Firefighter Eric T. Olsen, Ladder Co. 15 Firefighter Jeffrey J. Olsen, Engine Co. 10 Firefighter Steven J. Olson, Ladder Co. 3 Firefighter Kevin M. O’Rourke, Rescue Co. Firefighter Michael J. Otten, Ladder Co. 35 

Firefighter Jeffrey A. Palazzo, Rescue Co. Firefighter Frank Palombo, Ladder Co. 105 Firefighter James N. Pappageorge, Engine Firefighter Robert E. Parro, Engine Co. 8 Firefighter Durrell V. Pearsall, Rescue Co. Firefighter Christopher J. Pickford, Engine Firefighter Shawn E. Powell, Engine Co. 20Firefighter Vincent A. Princiotta, Ladder CoFirefighter Kevin M. Prior, Squad Co. 252 Firefighter Lincoln Quappe, Rescue Co. 2 Firefighter Leonard J. Ragaglia, Engine CoFirefighter Michael P. Ragusa, Engine Co. Firefighter Edward J. Rall, Rescue Co. 2 Firefighter Adam D. Rand, Squad Co. 288 Firefighter Donald J. Regan, Rescue Co. 3 Firefighter Christian Regenhard, Ladder CoFirefighter Kevin O. Reilly, Engine Co. 207 
TEN HOUSE 9/11 WTC MEMORIAL BRONZE

Fire Department, City of New York

9 MetroTech Center 

Brooklyn, New York 11201

www.nyc.gov/fdny