When the WTC buildings collapsed on September 11, 2001, an estimated 250,000 to 400,000 people in the vicinity were immediately exposed to a noxious mixture of dust, debris, smoke, and potentially toxic contaminants in the air and on the ground, such as pulverized concrete, fibrous glass, particulate matter, and asbestos. Those affected included people residing, working, or attending school in the vicinity of the WTC and thousands of emergency responders. Subsequently, an estimated 40,000 responders who were involved in some capacity in the days, weeks, and months that followed, including personnel from many government agencies and private organizations as well as other workers and volunteers, were also exposed. A wide variety of physical and mental health effects have been observed and reported among people who were involved in rescue, recovery, and cleanup operations and among those who lived and worked in the vicinity of the WTC. Many health effects have persisted or worsened over time. Physical health effects included injuries and respiratory conditions, such as sinusitis, asthma, and a new syndrome called WTC cough, which consists of persistent coughing accompanied by severe respiratory symptoms. Almost all firefighters who responded to the attack experienced respiratory effects, including WTC cough. A recent study suggested that exposed firefighters on average experienced a decline in lung function equivalent to that which would be produced by 12 years of aging. Commonly reported mental health effects among responders and other affected individuals included symptoms associated with posttraumatic stress disorder—an often debilitating disorder that can develop after a person experiences or witnesses a traumatic event, and which may not develop for months or years after the event. Behavioral effects such as alcohol and tobacco use and difficulty coping with daily responsibilities have also been reported. The five programs that were created for monitoring the health of WTC responders vary in aspects such as the implementing agency (i.e., federal, state, or local governments or private organizations) and eligibility requirements. (See table 1.) Each program received federal funding, the majority of which was provided by the Department of Homeland Security’s Federal Emergency Management Agency (FEMA), as part of the approximately $8.8 billion in federal assistance that the Congress appropriated to FEMA for response and recovery activities after the WTC disaster. FEMA is authorized to use a portion of its WTC-related funding for screening and long-term monitoring of responders. With regard to treatment, however, FEMA may generally fund only short-term care after a disaster, such as emergency medical services, and not ongoing clinical treatment. FEMA entered into interagency agreements with HHS to fund most of the health monitoring programs. OPHEP, which coordinates and directs HHS’s emergency preparedness and response program, entered into separate interagency agreements with FOH to implement the federal responder screening program for current federal workers and with NIOSH to implement the screening program for former federal workers. We reported in February 2006 that four of the five monitoring programs had made progress in screening and monitoring affected individuals and gathering data. (See table 1.) These four programs—the FDNY WTC Medical Monitoring Program, the worker and volunteer WTC program, the New York State responder screening program, and the WTC Health Registry—had collected information that monitoring officials said could be used by researchers to help better understand the health consequences of the attack and improve treatment, such as by identifying which types of treatment are effective for specific conditions. In contrast to the progress made by the other programs, the HHS WTC Federal Responder Screening Program had lagged behind and accomplished little. The program was established to provide free voluntary medical screening examinations for federal workers whom their agencies sent to respond to the WTC disaster from September 11, 2001, through September 10, 2002, and who were not eligible for any other WTC health monitoring program. Through March 2004, the program—which started about a year later than the other WTC monitoring programs—completed screenings of 394 federal workers. HHS put the program on hold in January 2004, when it stopped scheduling new examinations, because it wanted to resolve several operational issues, including HHS’s determination that FOH did not have the authority to provide examinations to people who are no longer in federal service. Under an agreement between OPHEP and FOH that was established in July 2005, the program resumed providing examinations for current federal workers in December 2005, and in February 2006, OPHEP executed an agreement with NIOSH calling for NIOSH to arrange for the worker and volunteer WTC program to provide examinations to former federal workers. Many participants in the monitoring programs required additional testing or needed treatment for health problems that were identified during screening examinations. The FDNY WTC Medical Monitoring Program referred participants to the FDNY Bureau of Health Services, but the other programs primarily referred participants to their primary care physician or to privately funded programs available to responders, such as treatment services provided by the Mount Sinai clinical center that are funded by the American Red Cross. We previously reported that officials told us that finding treatment services for such participants was an important, but challenging, part of the programs’ responsibility. For example, officials from the worker and volunteer WTC program stated that identifying providers available to treat participants became a major part of their operations, and was especially difficult when participants lacked health insurance. In December 2005, the Congress appropriated $75 million to CDC to fund programs providing baseline screening, long-term monitoring, and health care treatment for emergency services and recovery personnel who responded to the WTC disaster. The law required CDC to give first priority to programs coordinated by the FDNY-BHS, Mount Sinai-Irving J. Selikoff Center for Occupational and Environmental Medicine, and New York City Department of Health and Mental Hygiene, which have existing monitoring programs, and to programs coordinated by the POPPA program and Project COPE. The mission of the POPPA program, which offers peer-to- peer mental health counseling to New York City Police Department (NYPD) officers, is to reduce unresolved emotional trauma that can result in problems ranging from poor performance to suicide. The POPPA program counseled over 5,000 NYPD officers in the 10 months following the WTC attack. Project COPE, a collaboration of the New York City Police Foundation and Columbia University Medical Center, uses a hotline and outreach efforts to encourage NYPD uniformed and civilian employees to obtain mental health services, which are provided by Columbia University Medical Center and private providers. As of August 2006, over 18,000 employees had attended educational sessions held at police facilities, and over 5,000 had received individual counseling or therapy consultations. Since February 2006, an additional 1,385 federal responders have registered for screening examinations, bringing the total number registered on the WTC Federal Responder Screening Program Web site to 1,762 as of late August 2006, including 283 former federal workers. Because the total number of federal responders involved in the WTC disaster is uncertain, it is not possible to determine what proportion of the total number of federal responders have registered. HHS’s efforts to conduct outreach to federal agencies resulted in the identification of 2,200 federal responders. As of late August 2006, FOH had completed screening examinations for a total of 907 federal workers, 380 of whom were screened since February 2006. Through OPHEP’s agreement with NIOSH, the worker and volunteer WTC program has provided screening examinations to 13 former federal workers and scheduled 11 more. Most of the former federal workers reside outside the New York metropolitan area, where the worker and volunteer WTC program is located, and NIOSH is working to establish a national network of providers to screen these workers. HHS reported that as of late August 2006, a total of 1,762 federal responders had registered for screening examinations on the WTC Federal Responder Screening Program Web site, including 1,479 current federal workers and 283 former federal workers. Of the 1,762 federal responders who registered, 1,385 had registered since February 2006, including 1,134 current federal workers and 251 former federal workers. It is not possible to determine what proportion of the total number of federal responders involved in the WTC disaster have registered because the total number involved is uncertain. In determining the total number of individuals eligible for its program, the WTC Health Registry developed an estimate of 8,621 federal responders, based on information from 31 federal agencies in the New York area and information from FEMA on 22 Urban Search and Rescue teams that were deployed to the WTC area. This estimate does not account for all federal responders from other geographic areas. As we reported previously, in the aftermath of the WTC disaster, HHS did not have a comprehensive list of all federal agencies and federal responders who were involved. In an effort to develop such a list, OPHEP and ATSDR entered into an agreement in April 2005 for ATSDR—which had developed the WTC Health Registry—to identify and register federal responders. Under the agreement, ATSDR, through a contractor, contacted federal agencies, developed a list of WTC federal responders, and conducted outreach to encourage the responders to register on the new Web site that the contractor established. As a result of this effort, 46 federal agencies were identified and provided contact information for 2,200 federal responders. The agreement between OPHEP and ATSDR expired on April 30, 2006, ending the outreach efforts to federal agencies. Under an agreement with OPHEP, NIOSH assumed responsibility for maintaining the WTC Federal Responder Screening Program Web site through December 31, 2006. As of late August 2006, FOH had completed screening examinations for a total of 907 of the federal workers who had registered; 380 of the 907 were screened since February 2006. Under its agreement with OPHEP, FOH is responsible for regularly retrieving from the registration Web site requests for screening examinations for current federal workers and for assigning individuals to a provider for screening. FOH officials told us that they contact the individual and the provider to inform them of the need to arrange an appointment for screening.