On 11 September 2001, attacks on the World Trade Center (WTC) killed nearly three thousand people and exposed hundreds of thousands of rescue and recovery workers, passersby, area workers, and residents to varying amounts of dust and smoke. Former New York City Mayor Rudy Giuliani ordered the emergency evacuation of Lower Manhattan below Canal Street, but not all residents evacuated. Previous studies showed that those who did not evacuate had a higher incidence of newly diagnosed asthma. Among the 71,424 who enrolled in the WTC Health Registry in 2003-2004, we evaluated the bivariate association of educational attainment, household income, and race or ethnicity with reported evacuation on or after 9/11/01. We used log binomial regression to assess the relative risks of not evacuating from their home following the 9/11 attacks, adjusting for age, gender, and marital status. Out of a total of 11,871 enrollee residents of Lower Manhattan, 7345 or 61.79% reported evacuating their home on or after 9/11. In a fully adjusted model, the estimated relative risk for not evacuating was elevated for those who identified as non-Hispanic Black, Asian/Pacific Islander, and Hispanic residents compared to non-Hispanic White residents. Residents with a high school diploma/GED had an elevated estimated risk compared to those with at least a bachelor\'s degree. Those with lower household incomes had an elevated estimated risk compared to those with the highest income category. These significant inequities will need to be prevented in future disasters.

Studies of the health impacts of the 11 September 2001 terrorist attacks on New York City\'s (NYC\'s) World Trade Center (WTC) towers have been hindered by imprecise estimates of exposure. We sought to identify potential biomarkers of WTC exposure by measuring trace and major metal concentrations in lung tissues from WTC-exposed individuals and less exposed community controls. We also investigated associations of lung tissue metal concentrations with self-reported exposure and respiratory symptoms. The primary analyses contrasted post-mortem lung tissue concentrations obtained from autopsies in 2007-2011 of 76 WTC Health Registry (WTCHR) enrollees with those of 55 community controls. Community controls were frequency-matched to WTCHR decedents by age at death, calendar quarter of death, gender, race, ethnicity and education and resided at death in NYC zip codes less impacted by WTC dust and fumes. We found WTCHR decedents to have significantly higher iron (Fe) lung tissue concentrations than community controls. Secondary analyses among WTCHR decedents adjusted for sex and age showed the log(molybdenum (Mo)) concentration to be significantly associated with non-rescue/recovery exposure. Post hoc analyses suggested that individuals whose death certificates listed usual occupation or industry as the Sanitation or Police Departments had elevated lung tissue Fe concentrations. Among WTCHR decedents, exposure to the WTC dust cloud was significantly associated with elevated lung tissue concentrations of titanium (Ti), chromium (Cr) and cadmium (Cd) in non-parametric univariable analyses but not in multivariable analyses adjusted for age and smoking status. Logistic regression adjusted for age and smoking status among WTCHR decedents showed one or more respiratory symptoms to be positively associated with log (arsenic (As)), log(manganese (Mn)) and log(cobalt (Co)) concentrations, while new-onset wheezing and sinus problems were negatively associated with log(Fe) concentration. Fe concentrations among individuals with wheezing, nonetheless, exceeded those in community controls. In conclusion, these data suggest that further research may be warranted to explore the utility as biomarkers of WTC exposure of Fe in particular and, to a lesser extent, Mo, Ti, Cr and Cd in digestions of lung tissue.

In 2021, and average of 220 deaths from opioid-related overdoses occurred daily in the US. Recent evidence suggests there is an association between post-traumatic stress disorder (PTSD) and increased opioid misuse, while little is known about opioid-related hospitalizations. This study used data from the World Trade Center Health Registry (WTCHR), a longitudinal cohort consisting of individuals directly exposed to the September 11th terrorist attacks with a high prevalence of resulting PTSD (3.8-29.6%). We linked WTCHR data to New York State hospitalization data to examine the question: do opioid-related hospitalizations (first time and repeated) differ by PTSD status. In a study sample of 37,968 adults, 145 experienced at least one episode of opioid-related hospitalization and 64 had repeated episodes during the study period. We found that in the 13-years post-9/11, individuals with PTSD had a significantly higher risk of a first-time opioid-related hospitalization (Hazard Ratio: 3.6, 95% CI: 2.7, 5.0) and repeated opioid-related hospitalizations (Hazard Ratio: 3.9, 95% CI: 2.7, 5.8) than those who did not have PTSD. Improved treatment of and increased screenings for PTSD may reduce the likelihood of opioid misuse in this population and consequently overdoses, hospitalizations, and healthcare costs.

We examined the all-cause and COVID-19-specific mortality among World Trade Center Health Registry (WTCHR) enrollees. We also examined the socioeconomic factors associated with COVID-19-specific death. Mortality data from the NYC Bureau of Vital Statistics between 2015-2020 were linked to the WTCHR. COVID-19-specific death was defined as having positive COVID-19 tests that match to a death certificate or COVID-19 mentioned on the death certificate via text searching. We conducted step change and pulse regression to assess excess deaths. Limiting to those who died in 2019 (n = 210) and 2020 (n = 286), we examined factors associated with COVID-19-specific deaths using multinomial logistic regression. Death rate among WTCHR enrollees increased during the pandemic (RR: 1.70, 95% CL: 1.25-2.32), driven by the pulse in March-April 2020 (RR: 3.38, 95% CL: 2.62-4.30). No significantly increased death rate was observed during May-December 2020. Being non-Hispanic Black and having at least one co-morbidity had a higher likelihood of COVID-19-associated mortality than being non-Hispanic White and not having any co-morbidity (AOR: 2.43, 95% CL: 1.23-4.77; AOR: 2.86, 95% CL: 1.19-6.88, respectively). The racial disparity in COVID-19-specific deaths attenuated after including neighborhood proportion of essential workers in the model (AOR:1.98, 95% CL: 0.98-4.01). Racial disparities continue to impact mortality by differential occupational exposure and structural inequality in neighborhood representation. The WTC-exposed population are no exception. Continued efforts to reduce transmission risk in communities of color is crucial for addressing health inequities.

Fetal growth is affected by exposure to both prenatal stress and environmental contaminants. The attacks on the World Trade Center (WTC) resulted in exposure to chemicals and psychological stress amongst New York City residents. We measured prenatal maternal stress and exposure to persistent organic pollutants (polybrominated diphenyl ethers, polychlorinated biphenyls, and polychlorinated dibenzo-p-dioxins (PCDDs)) in 108 participants from a Columbia University WTC birth cohort. Principal component (PC) analyses were conducted to characterize the mixture of exposure to the three groups of chemicals. We evaluated the associations between geographical exposures (proximity to the WTC disaster) and both chemical exposures (PCs) and stress (demoralization). We then evaluated the effect these exposures (PCs and stress) had on previously reported associations between geographical WTC exposure and birth outcomes (birth weight and birth length) in this study population to understand their individual roles in the observed associations. Geographical exposure via proximity to the WTC was associated with the PC reflecting higher PCDD exposure (PC3) (β = 0.60, 95% CI: 0.03, 1.18 for living/working within 2 miles of the WTC; and β = 0.73, 95% CI = 0.08, 1.38 for living within 2 miles of WTC). Previously reported reductions in birth weight and length associated with WTC proximity (β = -215.2, 95% CI: -416.2, -14.3 and β = -1.47, 95% CI: -2.6, -0.34, respectively) were attenuated and no longer significant for birth weight (β = -156.4, 95% CI: -358.2, 45.4) after adjusting for PC3, suggesting that PCDDs may act as partial mediators in this previously observed association. The results of this study can help focus future research on the long-term health effects of these prenatally exposed populations.

OBJECTIVE: Cancer can be a life-threatening stressor that may evoke pre-existing post-traumatic stress disorder (PTSD). We assessed change in 9/11-related PTSD symptoms following cancer diagnosis in a 9/11-exposed cohort, the World Trade Center Health Registry.
METHODS: We examined enrollees who had a first-time post-9/11 invasive cancer diagnosis and at least one pre- and two post-diagnosis 9/11-related PTSD assessments from enrolment through 2015. PTSD symptoms were measured using 17-item PTSD Checklist (PCL, range 17-85). Cancer was identified from New York State Cancer Registry and categorized as localized or advanced stage. We used piecewise spline linear mixed-effects models to examine rate of change in PCL scores from pre- to post-diagnosis periods, and whether the change differed by gender or stage, with time as fixed and random effects, adjusting for baseline age, race, and education.
RESULTS: 9/11-related PTSD symptoms were slightly increasing in the pre-diagnosis period, while this trend reversed in the post-diagnosis period (β: -0.38; 95% CI: -0.60, -0.15). This trend was driven by male rescue/recovery workers (RRW), among whom significant decrease in rate of change in PCL scores was observed for those with advanced stage (slope change difference [95% CI]: -1.81 [-2.73, -0.90]). No significant difference in rate of change was observed among non-RRW. Among females, PCL scores tended to decrease slightly, with no significant difference in rate of change between pre- and post-diagnosis periods.
CONCLUSIONS: We observed significant reduction in the rate of change in 9/11-related PTSD symptoms among male RRW. The underlying mechanism is unknown, necessitating future research.

Perfluoroalkyl substances (PFAS) were among various persistent organic pollutants suspected to have been released during the collapse of the World Trade Center (WTC) on 9/11. Evidence on the association between prenatal PFAS exposure and child neurodevelopment is limited and inconsistent. This study evaluated the association between prenatal PFAS exposure and child cognitive outcomes measured at 5 different time points in a population prenatally exposed to the WTC disaster. The study population included 302 pregnant women in the Columbia University WTC birth cohort enrolled between December 13, 2001 and June 26, 2002 at three hospitals located near the WTC site: Beth Israel, St. Vincent\'s, and New York University Downtown. We evaluated the association between prenatal exposure to four PFAS (perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexanesulfonic acid (PFHxS), perfluorononanoic acid (PFNA)) and child neurodevelopment measured using the Bayley Scales of Infant Development (BSID-II) at approximately 1, 2 and 3 years of age and using The Wechsler Preschool and Primary Scale of Intelligence (WPPSI) at approximately 4 and 6 years of age. Geometric mean (range) concentrations of PFAS were 6.03 (1.05, 33.7), 2.31 (0.18, 8.14), 0.43 (

Prior studies have found that rescue and recovery workers exposed to the 9/11 World Trade Center (WTC) disaster have evidence of increased persistent hearing and other ear-related problems. The potential association between WTC disaster exposures and post-9/11 persistent self-reported hearing problems or loss among non-rescue and recovery survivors has not been well studied.
We used responses to the World Trade Center Health Registry (Registry) enrollment survey (2003-2004) and first follow-up survey (2006-2007) to model the association between exposure to the dust cloud and persistent hearing loss (n = 22,741).
The prevalence of post-9/11 persistent hearing loss among survivors was 2.2%. The adjusted odds ratio (aOR) of hearing loss for those who were in the dust cloud and unable to hear was 3.0 (95% CI: 2.2, 4.0). Survivors with persistent sinus problems, headaches, PTSD and chronic disease histories had an increased prevalence of reported hearing problems compared to those without symptoms or chronic problems.
In a longitudinal study, we observed an association between WTC-related exposures and post-9/11 self-reported hearing loss among disaster survivors.

Perfluoroalkyl substances (PFAS) were among various persistent organic pollutants suspected to have been released during the collapse of the World Trade Center (WTC) on 9/11/2001. Evidence suggests that PFAS may have cardiometabolic effects, including alterations in lipid profiles. This study evaluated the association between cord blood PFAS and lipids in a population prenatally exposed to the WTC disaster.
222 pregnant women in the Columbia University WTC birth cohort enrolled between December 13, 2001 and June 26, 2002 at hospitals located near the WTC site: Beth Israel, St. Vincent\'s, and New York University Downtown.
We evaluated the association between 5 cord blood PFAS-perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexanesulfonic acid (PFHxS), perfluorononanoic acid (PFNA), perfluorodecane sulfonate (PFDS)-and cord blood lipids (total lipids, total cholesterol, triglycerides).
Median (interquartile range [IQR]) concentrations of PFAS were 6.32 (4.58-8.57), 2.46 (1.77-3.24), 0.38 (0.25-0.74), 0.66 (0.48-0.95) and 0.11 (0.09-0.16) ng/mL for PFOS, PFOA, PFNA, PFHxS, and PFDS, respectively. Median (IQR) for lipids were 59.0 (51.5-68.5) mg/dL for total cholesterol, 196.5 (170.5-221.2) mg/dL for total lipids and 33.1 (24.2-43.9) mg/dL for triglycerides. In fully adjusted models, several PFAS were associated with higher lipid levels, including evidence of a strong linear trend between triglycerides and both PFOA and PFHxS.
Findings support previous evidence of an association between PFAS exposure and altered lipid profiles and add novel information on this relationship in cord blood, as well as for an understudied PFAS, PFDS (J Clin Endocrinol Metab XX: 0-0, 2019).

UNASSIGNED: This study examined whether World Trade Center (WTC) exposures and chronic posttraumatic stress disorder (PTSD) were associated with incidence of mild cognitive impairment (MCI) in a longitudinal analysis of a prospective cohort study of WTC responders.
UNASSIGNED: Incidence of MCI was assessed in a clinical sample of WTC responders (N = 1800) who were cognitively intact at baseline assessment. Crude incidence rates were calculated and compared to population estimates using standardized incidence ratios. Multivariable analyses used Cox proportional-hazards regression.
UNASSIGNED: Responders were 53.1 years old (SD = 7.9) at baseline. Among eligible cognitively intact responders, 255 (14.2%) developed MCI at follow-up. Incidence of MCI was higher than expected based on expectations from prior published research. Incidence was higher among those with increased PTSD symptom severity, and prolonged exposure was a risk factor in apolipoprotein-ε4 carriers.
UNASSIGNED: PTSD and prolonged WTC exposures were associated with increased incidence of MCI in WTC responders, results that may portend future high rates of dementia in WTC-exposed responders.