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CDC Telebriefing Transcript

9-11-02 Special Issue Examines Health Effects Related to World Trade Center Terrorist Attacks

September 9, 2002

CDC MODERATOR: Thank you, and good afternoon. Thank you all for joining us today. I have just a couple of announcements before we get started. As most of you have probably figured out by now, this is a special issue of MMWR that is actually out for publication on September 11th. However, the embargo is lifting with this telebriefing, as is the typical MMWR telebriefing practice.

Also, New England Journal of Medicine has three articles: Cough and Bronchial Responsiveness in Firefighters at the World Trade Center Site; a review article on respiratory protection; and an editorial on World Trade Center Cough--A Lingering Legacy and a Cautionary Tale. They are also coming off embargo right now to coincide with this telebriefing.

Today's telebriefing will feature three articles from a special September 11th issue of MMWR. All of these are dealing with the health effects of the World Trade Center attacks. Our first speaker today will be Dr. Rachel Kramer. She's with the New York City Department of Health and Mental Hygiene. She will discuss a Lower Manhattan community survey conducted by the New York City Health Department along with CDC. Randolph Daley from CDC and several representatives from the New York City Health Department will also be available to answer questions on this article during the Q&A segment.

Following Dr. Kramer, we will hear from Dr. David Prezant of the New York City Fire Department. He will be discussing a report on injuries and illnesses among New York City Fire Department rescue workers in the aftermath of theoretically World Trade Center attacks.

And finally, we'll hear from Dr. Bruce Bernard of CDC's National Institute for Occupational Safety and Health, NIOSH, who will discuss findings of a study on the health effects suffered by workers at a school and college near the World Trade Center compared to a similar group of workers at least five miles away from the World Trade Center. One of the co-authors of that article, Dr. Sherry Baron, will also be available during the Q&A segment.

And as always, following the three speakers' comments, we will open it up for reporter questions. I think we can get started now. Let's begin with Dr. Kramer.

DR. KRAMER: Okay. Soon after the attack on the World Trade Center, the New York City Department of Health and Mental Hygiene, in collaboration with the CDC, conducted a community needs assessment in Lower Manhattan. To identify the health-related needs and concerns of persons living in the immediate area surrounding the World Trade Center site, we surveyed a representative random sample of households in Lower Manhattan. The primary purpose of the survey was to gather information to set priorities and direct public health interventions related to the needs of the residential population. Some of you may be aware that select findings from this project were reported in January in the New York City media.

During the period between October 25th and November 2, 2001, about six weeks following the attack on the World Trade Center, a door-to-door survey was conducted in three residential neighborhoods representing approximately 50 percent of the Lower Manhattan residential population. Four hundred fourteen participating households were asked questions about exposure to the World Trade Center attack, physical and mental health status, access to services, and urgent needs and concerns.

The overall findings indicate that although basic community services were available six weeks after the attacks, a large proportion of respondents had physical and psychological symptoms potentially associated with the exposure and needed information to address their health and safety concerns. Some specific findings from the survey are as follows:

Overall, an estimated 75 percent of the households were evacuated from their homes following the attacks. Approximately 55 percent of the adult population witnessed the collapse of the World Trade Center towers, 29 witnessed persons being injured or killed, and 48 percent knew someone who died as a result of the attacks.

The symptoms most frequently reported as developing or increasing after September 11th were nose or throat irritations, in 66 percent of the population; eye irritation or infection, in 50 percent; and coughing, in 47 percent. At the time of the survey, these symptoms were still a problem in approximately 82 percent.

An estimated 39 percent of the adult population had a high score on a screening instrument for post-traumatic stress disorder, or PTSD, indicating a need for further mental health evaluation and a potential for PTSD. An estimated 28 percent of the adult population had received some type of supportive counseling at the time of the survey. A total of 39 percent thought they would benefit from any or additional supportive counseling, and of these, 34 percent reported not have adequate access to this kind of support.

And finally, approximately 61 percent of the population reported receiving information about proper cleaning procedures, yet only 45 percent reported that their apartments had been cleaned according to the recommended method.

On the basis of the results of the survey, the New York City Department of Health and Mental Hygiene responded to resident concern, helped reduced exposure to dust and debris, and provided information about mental health resources. We initiated focused outreach to Lower Manhattan neighborhoods through presentations with tenant associations and community groups to share information and provide a forum for questions and concerns.

Materials were developed and disseminated regarding environmental issues and related health problems--current air and dust testing results and their implications, recommendations for cleaning up and reducing further exposures, psychological effects, and availability of relief services and mental health services. These outreach activities continued through the spring of 2002.

The New York City Department of Health and Mental Hygiene was able to provide an important service for this community by giving residents timely and comprehensive information, but also providing an opportunity for persons living near the World Trade Center site to voice their concerns to government agencies in the aftermath of the disaster.

CDC MODERATOR: Thank you, Dr. Kramer. Now we will hear from Dr. David Prezant with the New York City Fire Department.

DR. PREZANT: Just give me one second. I'm coming right on. Just give me one minute.

Okay. I just had to pull over. Sorry.

Okay. On September 11th of 2001, the New York City Fire Department responded immediately to the collapse of the World Trade Center. On that day, over 343 FDNY rescue workers died during the collapse--341 were New York City firefighters, and two were New York City FDNY paramedics.

Over the next 24 hours, an additional 240 FDNY rescue workers--firefighters and paramedics are included in the term "rescue workers"--sought emergency medical treatment. And this report in today's MMWR details the injuries and illnesses, both during the first 24 hours of that day as well as the next 11 months.

For instance, in the first 24 hours, 63 percent suffered eye injuries, of which the vast majority were eye irritations due to exposure to fine particulate airborne matter. Twenty percent suffered respiratory tract irritation requiring hospital evaluation. Eight had chest pain, with subsequent evaluation not revealing any evidence for myocardial infarction. There were no myocardial infarction in any FDNY rescue worker that day or over the subsequent weeks.

There were significant life-threatening inhalation injuries in the first 24 hours in several firefighters. One had a severe inhalation injury with both upper and lower airway damage, severe swelling of the upper airway requiring an emergency tracheostomy, and then developed adult respiratory distress syndrome requiring prolonged mechanical ventilation. We are happy to report that that firefighter had fully recovered from his respiratory injuries.

Another firefighter had a respiratory arrest during the collapse of World Trade Center Tower No. 7, which happened later that afternoon. It's interesting that no one talks about the World Trade Center Tower No. 7 collapse because it's several hours after the collapse of Towers 1 and 2. However, that was a major skyscraper as well.

Of note, this firefighter was found accidentally when other firefighters were searching the area. If it had not been for that, he would have died that day as well. He was intubated on the scene, evacuated, and recovered from massive bronchospasm, extubated, but now still suffers the effects of new-onset asthma or reactive airways dysfunction syndrome.

Asthma is a contraindication for employment to the New York City firefighter but not for employment as an EMS worker. Therefore, one EMT was hospitalized for status asthmaticus, a severe asthma exacerbation. That totals, therefore, three firefighters or EMTs that were admitted for life-threatening inhalation injury.

There were several other firefighters admitted for pneumothorax, with or without rib fractures. And this article details the large numbers of traumatic injuries of which many of them were fractures, some of them requiring months of hospitalization.

Over the next three months, we report on orthopedic injuries because many of the orthopedic injuries that resulted in that day and over the next several days remained underreported during that initial time period. Those orthopedic injuries that did not require hospitalization, in other words, those that were not fractures, really most of the workers continued to work with so that they could be part of the important rescue activities that were ongoing.

Therefore, we totaled all the traumatic injuries for a three-month time period, including those on the first 24 hours. There was a 200 percent increase in crush injuries from what we normally have in the prior nine months, the average being three per month to now nine. There was a 35 percent increase in lacerations, from a normal average of 37 per month to 50 per month, and a 29 percent increase in fractures, from a normal average of 21 per month to 27. These levels have returned to normal over the next few months.

Interestingly, many orthopedic injuries that we normally suffer because New York City firefighters are exposed to many traumatic events, but, interestingly, many orthopedic injuries decreased during the first three months, again, we believe because of the safe work practices at the site and because of underreporting of injuries due to the pressing needs for rescue and recovery. These type of injuries were the minor ones such as sprains, strains, and contusions, et cetera.

Two other areas of interest are respiratory injuries--respiratory illnesses and stress-related illnesses. In the first two weeks after the attack, one additional New York City firefighter suffered severe respiratory complaints requiring NEER intubation, and he was subsequently found to have acute eosinophilic pneumonia, which has fully recovered with corticosteroid treatment, is now of steroids, and has returned to work.

Thirteen firefighters reported the incidence of pneumonia with lobar consolidation, but this is not an increased incidence from our previous numbers.

And then over 332 firefighters had noted severe respiratory-related cough and symptomatology. We call this the WTC-related cough, and we have a unique definition for this. Because so many of our firefighters have reported coughing, over 90 percent of the exposed workforce has reported an acute new or increased cough after exposure to WTC, we wanted to focus on those that were most urgently in need of medical assistance. So, therefore, for the purposes of this and other studies, we have defined the FDNY WTC cough as being severe enough to require at least four weeks of medical leave. When we do that, during the first six months post-World Trade Center, 332 firefighters and one EMS worker had severe FDNY WTC-related cough. These people suffer from both upper and lower aerodigestive tract irritation, including sinusitis, gastro-esophageal acid reflux, and asthma. Fifty-two percent have shown only partial improvement and remain on either medical leave, light duty, or are filing for retirement injury/disability evaluations. We expect that over 500 firefighters will ultimately file and probably qualify for retirement injury/disability on the basis of WTC cough and other respiratory-related problems. This is a dramatic increase from our prior numbers.

This data is also being reported, as was mentioned by Ms. Hunter, in this week's New England Journal of Medicine.

In terms of stress-related illnesses, we've had 17-fold increase in those firefighters asking for evaluation of stress-related incidents and severe enough to require temporary medical leave or light duty during that evaluation.

This 17-fold increase in hard number is an increase, 75 stress-related incidents reported in the prior 11 months compared to now 1,277. Of these, 37 also had respiratory problems.

There are even more who have required evaluation for stress but have not been severe enough to need medical leave or light duty.

That concludes my comments for this area.

CDC MODERATOR: Thank you, Dr. Prezant.

And now we'll hear from Dr. Bruce Bernard of CDC's National Institute for Occupational Safety and Health. Dr. Bernard?

DR. BERNARD: Thank you. CDC's National Institute for Occupational Safety and Health, or NIOSH, is releasing results of a study which found that workers employed at a high school and a college near the World Trade Center site reported symptoms of eye irritation, nose and throat irritation, cough, shortness of breath, depression, and post-traumatic stress that persisted four to six months after the September 11th attacks on the World Trade Center site.

Surveying about 950 employees at four work sites in January and March of 2002, we found that 20 to 30 percent of workers at the high school and college near the World Trade Center reported persistent symptoms of eye irritation, nose/throat irritation, cough, and shortness of breath. And approximately one-fourth to one-third of the high school and college staff reported symptoms consistent with major depression, and 15 to 23 percent had symptoms consistent with post-traumatic stress disorder.

These symptoms were statistically significantly higher than workers surveyed at two comparison sites, a college and a high school more than five miles from the World Trade Center site.

The similarity between the prevalence of symptoms and the types of symptoms in both the college and the high school is striking.

These symptoms indicate that the impact of the World Trade Center destruction extended beyond the site itself and beyond rescue and recovery workers to affect the health of workers in buildings nearby. And CDC NIOSH recommends that further assessment to describe the nature and extent of illness in specific working groups as well as individual medical follow-up be provided to address workers' occupational health needs and also to assess if those measures that are put in place are effective.

Thank you. That concludes my...

CDC MODERATOR: Thank you, Dr. Bernard.

And now I believe we're read to open it up to questions from reporters.

AT&T FACILITATOR: Very good. Ladies and gentlemen, at this time if you have a question, please depress the 1 on your touch-tone phone. You will hear a tone indicating you've been placed in queue. You may remove yourself from queue at any time by pressing the pound key. If you're using s speakerphone, please pick up the handset before pressing the number.

Again, for questions, please depress the 1 on your phone, and the first question comes from the line of John Lelleman (ph) from Bloomberg News. Please go ahead.

QUESTION: Hi. Thank you for taking my call. I'm wondering if there's anybody available to talk about another figure in the MMWR having to do with the number of deaths. Is that a final count or do we expect more? Is anybody able to comment on that?

CDC MODERATOR: Are you referring to the New York City Department of Health and Mental Hygiene--

QUESTION: That's right.

CDC MODERATOR: --statistics on the demographic breakdown of the World Trade Center victims?

QUESTION: On page 16 of the MMWR, yeah.

CDC MODERATOR: Okay. Is there anybody from the Health Department that can address that?

DR. KRAMER: I actually took that number from the New York Times article that was quoting the medical examiner's office. But I can't comment--comment on it beyond that.

CDC MODERATOR: Caller, if you'll call our press office--and I'll be giving that number at the end of this telebriefing--we can put you in touch with the appropriate expert for that.

QUESTION: You're saying that this figure on page 16, deaths in World Trade Center terrorist attacks, came from the New York Times?

DR. KRAMER: Well, it came from the medical examiner's office, from the New York City Department of Health and Mental Hygiene.

QUESTION: Okay. Thank you.

CDC MODERATOR: Next question, please.

AT&T FACILITATOR: The next question is from the line of Denise Grady from New York Times. Please go ahead.

QUESTION: This is for Dr. Prezant. I just want to be sure we understand. When you say 52 percent report only partial improvement, does that mean the other 48 percent have fully recovered?

DR. PREZANT: Yes, the other 48 percent with treatment have recovered and have returned to full duty, firefighting activity.

QUESTION: Okay. Can I ask a follow-up on this?


QUESTION: Okay. Is this any better or worse than what you might have expected? Are there any surprises here?

DR. PREZANT: Yeah, this is not--well, first off, we should emphasize that the 333 FDNY rescue workers that suffered WTC cough requiring at least four weeks of medical leave represents a small percentage of the total FDNY workforce that was exposed to the World Trade Center that day and subsequent days. The New York City firefighters, every one of them was exposed--practically everyone was exposed in the first week, and that's a total workforce of approximately 11,300. And the FDNY EMS workforce is around 2,900, but we think that only about 700 were exposed.

So this 333 is a small percentage. That itself is unique. Some might have thought that the percentage would be higher, especially since over 90 percent are reporting new onset cough or worsening of prior cough, but not to a level severe enough to impact on their daily activities.

We're doing further studies on pulmonary functions along with our partner, CDC NIOSH, to detail the effects of this exposure more thoroughly. However, the 48 percent that have recovered, we're thankful for that number, and it definitely reflects our aggressive evaluation and treatment protocols. But we would have expected a higher number. Based on prior smoke inhalation experiences, it's been our experience that closer to 90 percent recover from the events with similar treatment protocols.

CDC MODERATOR: Okay. Thank you.

Before we go to our next question, I just want to remind people typing on their computers to please put your phone on mute. And we'll take our next question now.

AT&T FACILITATOR: Our next question is from Malcolm Witter (ph) from Associated Press. Please go ahead.

QUESTION: Yes, Dr. Prezant, I just wanted to sort out a couple of your numbers here. You said 250 Fire Department rescue workers are on leave with stress-related problems, I assume all due to the World Trade Center. You said 37 of these also have respiratory problems, so are they part of the 358 on leave or light duty from respiratory illness? I'm just trying to figure out if there's some overlap in those figures.

DR. PREZANT: Yeah, the 37 don't represent the current 250 that are currently on medical leave--

QUESTION: Say that again. What now? The 37 what?

DR. PREZANT: The 37--let me just check these numbers for you. Give me one second.

There are 37 (?) with co-existent res (?) .

QUESTION: I'm sorry. There are 37 what? Hello?

CDC MODERATOR: I think we may have lost Dr. Prezant. He was on a cell phone. But he said he should be calling back, so when he comes back on the line, you can resume your question, but for now let's take another question.

QUESTION: You'll tell me when he comes back on the line, right?



AT&T FACILITATOR: Okay. We'll go on to our next question from Delfia Ricks (ph). Please go ahead.

QUESTION: My question was for Dr. Prezant, so if he's not on the line, I can't ask a question.

CDC MODERATOR: Okay. If we have some questions for either of the other two articles until we get Dr. Prezant back on the line?

AT&T FACILITATOR: Okay. We can come back to those other participants. The next one is from Kathleen Dohaney (ph) from Please go ahead.

QUESTION: This may be for Dr. Prezant, but maybe someone else can answer it. On World Trade Center cough, a couple of questions. What's the treatment? What's the prognosis? And can it be compared to any other type of cough?

CDC MODERATOR: Are any of our other speakers able to address that question?

AT&T FACILITATOR: Dr. Prezant is back on line.


QUESTION: Do you want me to re-ask?


QUESTION: For Dr. Prezant or anyone else, Kathleen Dohaney from Healthscout News. What's the treatment for World Trade Center cough? What's the prognosis? And can it be compared to any other type of cough?

DR. PREZANT: Yes, hi, this is Dr. Prezant. I'm sorry I got disconnected before.

The treatment for World Trade Center cough is understanding that it's a combined irritation of both the aero and digestive tract. It's not just a lower airway injury. It's an involvement of both the sinuses, the throat, the lower airways, and also an involvement of the esophageal tract.

This inhalation was also a fine particulate matter that deposited in the nose, the sinuses, the throat, was swallowed, and, therefore, irritated the esophageal tract, and a small amount was also inhaled.

When you realize that it affects all of those organs and you understand what prior respiratory studies have shown, that is to say, that if you have a current sinus drip or acid reflux from the stomach, what's referred to as gastro-esophageal reflux disorder, or GERD, or more simply in layman's language "heartburn," if you have any of those issues, your cough has trouble resolving. And people with chronic cough from other studies have shown that you need to solve those problems as well.

So the treatment of WTC cough, once you understand that it involves a multi-system approach, is to treat the sinus drip, the gastro-esophageal reflux disorder, as well as the bronchial hyperreactivity/asthma, and the combinations used for that would be decongestants, acid agents such proton pump inhibitors, and bronchodilators with inhalants, corticosteroids. With that we had, as I said, a 48 percent improvement in our sick--well, all of our people have improved, but 48 percent have improved to the ability to getting back to normal, off medication, and that has been a big success for us.

CDC MODERATOR: And, AT&T Operator, I think we can go back to the two earlier questions for Dr. Prezant.

AT&T FACILITATOR: We sure can. We'll go to Malcolm Witter. Please go ahead, sir.

QUESTION: Yes, Dr. Prezant, I just want to sort out some of your figures. I think you were looking this up when you left the line. Again, you have 250 rescue workers on leave with stress-related problems and then 37 of these also have respiratory problems, so I'm wondering, are they part of the 358 on leave for respiratory illness? Or what overlap is going on there?

DR. PREZANT: That is the overlap. You are correct in that.

QUESTION: So I can say that of the 358 on leave for respiratory illness, 37 of them also have stress-related problems? Is that--

DR. PREZANT: That's correct. It would be--the total of stress only currently on leave would be 250 minus 37.


DR. PREZANT: The reason why we point that out is not to confuse people about the numbers, but to highlight the fact that these are incredibly physically active people, they're having a tremendous amount of stress due to the loss of the World Trade Center Towers, the many civilians that they tried to save who, although they were able to evacuate over 25,000, every death is still a death that they wish they could take back. And then the 343 of their friends, co-workers who have died, that's stress enough. But then if you superimpose respiratory problems in a person who really defines himself in many ways by his physical abilities, you can see that there's added stress to this. This is the worst time for them to be suffering a co-existent medical illness, especially one that they intimately relate to their WTC exposure.

QUESTION: Yeah. Well, and similarly, when you say there might be 500 firefighters who eventually qualify for disability retirement, does that include those who have retired already from this?

DR. PREZANT: Yes, that does.

QUESTION: And so how many have already?

DR. PREZANT: At this point in time, no one has actually retired yet. There are many people in the pipeline.

QUESTION: I'm sorry. There are many people what?

DR. PREZANT: Many of these 500 people are in the pipeline. They have applications that are being processed, et cetera. But no one or very few have actually retired as of this date.

QUESTION: Okay. Thank you.

CDC MODERATOR: Okay. Thank you. And we'd like to take our next question.

AT&T FACILITATOR: We'll do to Delfia Ricks from Newsday. Please go ahead.

QUESTION: Well, he's basically answered the question now. I was concerned about the symptoms of World Trade Center cough, unless you want to go over them again.

CDC MODERATOR: No, I think that's fine. Then we'll take the next question.

CDC MODERATOR: The next question is from Andrew Weskin (ph) from New York Times. Please go ahead.

QUESTION: This is for Dr. Prezant. Thanks. I wanted to know if you could talk a little bit about the role of respirators, whether in the data you could say overall that there were benefits or--I understand--it looked like there was some problems that the respirators also caused, and I don't know if there's something you could conclude one way or the other for future episodes like this of what to do or whether the protocol that exists is correct.

DR. PREZANT: Well, before I give any comment on that, if needed, I'd like to introduce--reintroduce Dr. Bernard and Dr. Baron, who, along with us, did a study on respiratory use in FDNY rescue workers and, in fact, our findings are also in this current MMWR. So I'd like to first ask them to give their comments on this.

DR. BARON: Yeah, this is Dr. Baron. You'll see another article in the MMWR Report on the rates of self-reported use of respirators during the first two weeks by a sample of firefighters who responded to the attack. And you'll see there that, you know, a minority of firefighters were using adequate respiratory protection.

In addition--and we'll be reporting this in the future--we looked at relationships between self-reported respirator use and people who went on to develop either changes in pulmonary function or in respiratory symptomatology. But you'll see in those numbers there that it's hard to look at the protective effect of respirators because so few people were actually wearing them adequately at the time.

DR. PREZANT: The New York City Fire Department has the best respirator on the Planet Earth, and it's called the Self-Contained Breathing Apparatus. It's designed, however, to fight fires. So in that environment, you need total protection. You strap on an air tank so that you don't have any exposure to the external environment.

The unfortunate thing, however, is because it's designed for fires, it lasts only 8 to 15 minutes, and it's incredibly heavy. Once the World Trade Center Towers collapsed, this became for only a few a fire operation, and for most a rescue operation. And in that environment, the Self-Contained Breathing Apparatus, A, did not have enough time for its use, only 8 to 15 minutes, and, B, was way too heavy. So that our firefighters went in with the best respirator and the best intention for protection, but then did not have any respirator because of the resulting lack of ability to use the SCBA. It took, unfortunately, days to get them NIOSH-certified respirators, the half-face T100 respirator. During that time they tried to use hardware, sawdust masks, et cetera, but even that was of very limited value.

CDC MODERATOR: Thank you. We'll take our next question.

AT&T MODERATOR: The next question is from John Fascheck (ph) from the Washington (?) . Please go ahead.

QUESTION: Yes. Dr. Bernard mentioned that NIOSH was looking for further studies, I think it was community studies, and I was just wondering if he could elaborate a little bit on what kind of studies he'd be looking for. Would it be purely epidemiological? And if someone could review if there are any ongoing studies right now, any kind of ongoing surveying or tracking in that area?

DR. BERNARD: Yes, I guess you're referring to that we recommend further assessment to describe the nature of specific working groups. Right now, actually, the report that I gave today outlined two of the sites that NIOSH is currently involved in. We're also--this is part of a larger study where we're also assessing symptoms in various groups that were working around the World Trade Center site.

NIOSH, as far as individual--I also mentioned the need for individual medical follow-up to be provided to address workers' occupational health needs. At the present, NIOSH is not involved in any individual medical follow-up, and that is not what CDC-NIOSH is involved. We have recommended to these work sites that these studies that were performed by NIOSH were part of the Health Hazard Evaluation Program, which we included both the union groups involved in these work sites, the management, and also the Board of Education involved in the high school. And for the college, we also involved management of the college system and have been working with them to make sure that these groups assess the need for further services for their individual workers.

Does that answer you're question?

QUESTION: Yes, sure does. Thank you.

CDC MODERATOR: Thank you. Next question, please.

AT&T FACILITATOR: The next question is from Ted Vigotky [sp] from Public Broadcasting Atlanta.

QUESTION: Good morning. My question would be to either or both Dr. Kramer and Dr. Prezant. We've learned a lot in this year about how to tighten up the line of command and uniformity of communication equipment. If either or both of you could tell me anecdotally what protocols might be changed concerning counseling city workers for this post-traumatic stress or other mental problems. What have you learned over the year that the rest of the country can learn if, God forbid, we have another tragedy like this? Thank you.

CDC MODERATOR: This is the moderator. We'd really like to focus the telebriefing on the three articles from MMWR. I will be giving our press office number and we can refer you to the experts to answer other questions after this call.

QUESTION: Well, I believe part of the study had to do with post-traumatic stress. Is that correct?


DR. KRAMER: Well, our study, we did a screening, we used a screening tool for post-traumatic stress disorder, but we were just taking that measurement and not actually doing counseling. We were referring out. But there was a Project Liberty in the City of New York that was dealing with that, and we can refer you that number.

CDC MODERATOR: Thank you. Next question, please?

AT&T FACILITATOR: The next question is a follow-up question from Denise Grady from the New York Times.

QUESTION: Thank you. I want to ask Dr. Prezant, come back to something you said, and that was you mentioned from previous studies on smoke inhalation you would normally expect something like 90 percent to recover. Do you have any idea why it's worse here? Does it have to do with the nature of what was inhaled? Do we know anything about that? Are we talking just dust or is it chemicals or combustion products? What's different here?

DR. PREZANT: I think that we're never going to know the full scale of what firefighters were exposed to on that day. Most of the environmental monitoring that, by the way, has been reported, the summary report, in a prior issue of the MMWR, which I'm certain Ms. Hunter can give you the reference on, sometime in August of this year.

Most of that data was first begun collected on September 18th, seven and a half days after the towers fell. There is some data that started three days afterwards. We do not know what they were exposed to on day one, but the clear thing that every person knows is that they were exposed to a massive dust cloud. There is visual evidence for that. And that massive dust cloud includes a respirable airborne particulate matter.

Even if that respirable airborne particulate matter does not include a single chemical, it is incredibly toxic at that level of exposure. There are voluminous data in the literature saying that exposure to airborne particulates may induce increasing rates of chronic obstructive pulmonary disease, asthma, emphysema, and heart disease.

We're lucky that none of our firefighters had a myocardial infarct that day. But large numbers, as I've said, are coming down with asthma or reactive airways dysfunction syndrome. And we believe the difference between this exposure and prior fires is, number one, the volume of airborne particulate matter, and number two, the lengthy duration of exposure. Every one of the firefighters were there for many, many days during the first week and then for multiple re-exposures during the subsequent months.

CDC MODERATOR: Thank you. Next question.

AT&T FACILITATOR: Our next question is from Deb Krasnek [sp] from CNN.

QUESTION: I'm just wondering if--I'm listening to a lot of numbers here, which are hard for me to absorb all of them on the phone. Was there any lesson or any overall conclusion you drew from your findings--maybe something that could have been done better or differently or...

CDC MODERATOR: And that's for any of the three speakers?

QUESTION: Yeah, it's for any of the three speakers. I guess I'm having a hard time getting a handle on--I know you're listing a lot of findings, but I'm trying to sort to the trees and--

MS. BARON: This is Sherry Baron from NIOSH-CDC. I would say the one thing that we learned, particularly from the perspective of the workers who are employed in the vicinity but weren't the rescue and recovery workers, that there wasn't, I think, sufficient understanding at the time of the scope of individuals who could have been affected by this. And perhaps one of the lessons we can learn is the need to have adequate outreach programs and other kinds of services ready and available to a much wider group of people than we might have thought about at the time.

And I think, to me, that's really been something dramatic, that it wasn't just the rescue workers and the people working right directly on the pile, but people in the neighborhood and tens of thousands of people who came to work in that vicinity. And it took awhile for people to really become fully aware of the fact that those individuals also needed services and having things prepared for them.

CDC MODERATOR: Did any of the other speakers wish to comment on that question or answer the question?

DR. PREZANT: It think there were two major lessons on that day. I think the first lesson is that it would be great if the planes missed the World Trade Center towers. And I think the second lesson is that first responders respond, and they respond no matter what the danger to themselves is, both acute and chronic danger. They will be there. And because they were there, 25,000 civilians were successfully evacuated from the World Trade Center. And that can never be forgotten. Those are 25,000 families that still have their loved ones.

To the people that did that rescue effort and to the civilians who were exposed, we owe them long-term medical monitoring. Because clearly there are complaints, and our studies have documented significant functional abnormalities going along with those complaints. And we also believe that our aggressive evaluation and treatment has reduced the numbers of potential problems out there, at least in our work force.

So we really applaud the efforts of the CDC in organizing acute medical monitoring, and we hope that this effort will be continued over the long term.

CDC MODERATOR: Thank you. Next question, please.

AT&T FACILITATOR: We have a follow-up question from Malcolm Ritter from Associated Press.

QUESTION: Dr. Prezant, what can you say about the medical outlook for these 173 firefighters who've shown only partial improvement? What are you doing with them, and what can you tell them about what the future might bring?

DR. PREZANT: Well, I think on a positive note their coughs, wheezing, shortness of breath has improved with medical management, with management of their sinusitis, their gastro-esophageal reflux disorder, and their asthma. Life is becoming a little bit more livable.

But they're a long way off from the physically active, athletic firefighter. To return to their level of life, they would have to be fully recovered, off medication to return to a firefighting irritant environment. To return to the life of just an athlete, they would have to be a lot more stable on the medications that they're currently on.

But the good news is that their symptoms have, to a small or large extent, depending on the individual, ameliorated. They have severe worries about whether their respiratory condition will get worse over time and whether this is a harbinger for additional related illnesses or unrelated illnesses, such as cancer, et cetera.

The only way that we're going to be able to answer that question is with long-term medical monitoring. Prior studies have really been substantially affected by what's called longitudinal dropout, and that is that the most exposed, the most injured or ill workers or civilians following a massive disaster tend to disappear. They retire, they move out of town. They're affected; they want to get away. They're unable to stay in the work force.

And if you don't continue to reach those people in the subsequent years, your studies, A, are of little value because you've lost that work force. And number two, from a medical viewpoint, you're not able to serve the population that is in greatest need of your efforts. So that's why we'd like to structure this long-term medical monitoring and treatment program to begin now, rather than to begin 10 or 15 years from now, when the need might be more apparent, but the workers more difficult to find.

QUESTION: So it sounds like you really don't know what's going to happen to these guys, I mean medically.

DR. PREZANT: That's a short answer.

CDC MODERATOR: Thank you. Next question, please.

AT&T FACILITATOR: At this time we have no questions in queue.

CDC MODERATOR: Okay, thank you all for joining us. Anyone requiring additional information can contact CDC's press office. The phone number is (404) 639-3286. And as always, a transcript of this telebriefing will be available on the media relations website later this afternoon.

Once again, thank you all for joining us today.

Listen to the telebriefing

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