Research Trends in Respiratory Symptoms of Firefighters Exposed to the World Trade Center Disaster: 2001–2005 Mayris P. Webber,1 Jackson Gustave,2 Roy Lee,2 Justin K. Niles,1 Kerry Kelly,2 Hillel W. Cohen,3 and David J. Prezant1,2 1Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; 2Fire Department of the City of New York, Bureau of Health Services, Brooklyn, New York, USA; 3Albert Einstein College of Medicine, Bronx, New York, USA; Background : Respiratory symptoms, either newly reported after the World Trade Center (WTC) disaster on 11 September 2001 (9/11) or increased in severity, have been well documented in WTC-exposed workers and New York City residents. However, considerable uncertainty exists over the persistence of symptoms. o Bjectivs : In this study, our goals were to describe trends in post-9/11 respiratory and gastro- esophageal reflux disease (GERD) symptoms in WTC-exposed firefighters and to examine symptom progression in the cohort that completed both year 1 and year 4 questionnaires. Methods : We analyzed questionnaire responses from 10,378 firefighters in yearly intervals, from 2 October 2001 to 11 September 2005, defining exposure based on arrival time at the WTC site. For the cohort of 3,722 firefighters who completed the two questionnaires, we also calculated exposure duration summing months of work at the site. r sulte : In cross-sectional analyses, the prevalence of dyspnea, wheeze, rhinosinusitis, and GERD remained relatively stable, whereas cough and sore throat declined, especially between 1 and 2 years post-9/11. We found a dose–response relationship between arrival time and symptoms in all years (p < 0.01). Logistic models of symptoms at year 4 in the cohort demonstrated independent effects of earlier arrival and longer work duration: each additional month of work increased the odds of symptoms 8–11%. c onclusi : Protracted work exposures increased the odds of respiratory and GERD symptoms 4 years later. In most large disasters, exposures may be unavoidable during the rescue phase, but our data strongly suggest the need to minimize additional exposures during recovery and cleanup phases. k ey words : disaster medicine, firefighters, gastroesophageal reflux disease (GERD), occupa- tional medicine, rescue workers, respiratory symptoms, World Trade Center. Environ Health Perspect 117:975–980 (2009). doi:10.1289/ehp.0800291 available via http://dx.doi.org/ [Online 11 February 2009] The collapse of the World Trade Center (WTC) on 11 September 2001 (9/11) and subsequent recovery efforts released large amounts of particulate dust, combustion par- ticles, gases, fumes, and other noxious materi- als, some of which will remain incompletely characterized [Banauch et al. 2006; Centers for Disease Control and Prevention (CDC) 2002a; Edelman et al. 2003; Landrigan et al. 2004; Lioy et al. 2002; McGee et al. 2003; Mendelson et al. 2007], particularly the gas- eous component (Lioy et al. 2002). After the initial dust cloud settled, fires continued to be a major source of ongoing airborne contami- nation for months after the attack. The Fire Department, City of New York (FDNY), operated a continuous rescue/recovery effort at the site that lasted until July 2002 (Fireman et al. 2004; Prezant et al. 2002) and involved > 15,000 rescue workers [firefighters and emergency medical service (EMS) workers]. In the first 6 months after 9/11, the Bureau of Health Services (BHS) of FDNY identified 332 firefighters with “World Trade Center cough,” defined as a persistent cough that developed after exposure to the site and that was severe enough to require extensive medical leave (Prezant et al. 2002). In the same report, a range of frequent coexistent symptoms were identified, including dyspnea, wheeze, nasal congestion/drip, and acid reflux, that were con- sistent with asthma, rhinosinusitis, and gastro- esophageal reflux disease (GERD). Increased bronchodilator responsiveness and bronchial hyperreactivity were often noted in this and other studies (Banauch et al. 2003, 2005a; Prezant et al. 2002). A later study involving 12,079 FDNY rescue workers documented a decline in pulmonary function during the first year post-9/11 that was 12 times that found pre-9/11 (Banauch et al. 2006). An exposure– response gradient, based on arrival time at the WTC (Prezant et al. 2002), was consistently demonstrated for symptoms, bronchodilator responsiveness, bronchial hyperreactivity, and declines in pulmonary function. Respiratory symptoms, either newly reported post-9/11 or increased in severity, have also been docu- mented in other exposed workers (Herbert et al. 2006; Herbstman et al. 2005; Salzman et al. 2004; Tao et al. 2007; Wheeler et al. 2007) and residents (CDC 2002b; Lin et al. 2005; Reibman et al. 2005; Szema et al. 2004). Considerable uncertainty exists over the persistence of respiratory symptoms among WTC-exposed individuals because of a lack of long-term follow-up data. One earlier study reported on respiratory symptoms at Environmental Health Perspectives • volume 117 | number 6 | June 2009 three time points (pre-9/11, while working at the site, and 10–31 months post-9/11), but the first two time points were collected retrospectively and therefore were potentially subject to recall bias (Herbert et al. 2006). Another study evaluated symptom persistence at 1 and 20 months post-9/11 but focused exclusively on lower respiratory symptoms (LRS) in a convenience sample of 471 police officers (Buyantseva et al. 2007). The pres- ent study is the first to report the evolution of WTC respiratory symptoms in a large, highly exposed, homogeneous (similar fire- fighting job tasks) group (n = 10,378), with prospective follow-up over the first 4 years. We describe temporal trends in the preva- lence of post-9/11 aerodigestive symptoms [upper respiratory symptoms (URS), LRS, and GERD] through 11 September 2005. We further analyzed the progression of symp- toms in those firefighters (n = 3,722) that completed questionnaires during both the first and fourth years, thereby enabling assess- ment of four symptom patterns: early onset/ resolved, early onset/persistent, delayed onset, and asymptomatic initially and after 4 years (Buyantseva et al. 2007). Methods Since 1997, the FDNY BHS has performed periodic health evaluations on FDNY members approximately every 18 months; these evaluations include physician exami- nations and, since 2001, self-administered health questionnaires. The questionnaires are programmed on touch-screen com- puters, with trained personnel available to answer questions. Participation in the study required written informed consent and was Address correspondence to M. P. Webber, New York City Fire Department, Bureau of Health Services, 9 Metrotech Center, Brooklyn, NY 11201 USA. Telephone: (718) 999-2665. Fax: (718) 999-0142. E-mail: webberm@fdny.nyc.gov This work was supported by grant R01-OH07350 from the National Institute for Occupational Safety and Health. Employment of several of the authors by the Fire Department, City of New York (FDNY) in no way interfered with the authors’ freedom to design, con- duct, interpret, and publish research. J.G., R.L., K.K, and D.J.P. are employed by the FDNY. M.P.W., J.K.N., and H.C. declare they have no competing financial interests. Received 16 October 2008; accepted 10 February 2009. 975