Injuries and Illnesses Among New York City Fire Department Rescue Workers After Responding to the World Trade Center Attacks

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Within minutes of the terrorist attacks on September 11, 2001, the Fire Department of New York City (FDNY) operated a continuous rescue/recovery effort at the World Trade Center (WTC) site. Medical officers of FDNY Bureau of Health Services (FDNY-BHS) responded to provide emergency medical services (see box). The collapse of the WTC towers and several adjacent structures resulted in a vast, physically dangerous disaster zone. The height of the WTC towers produced extraordinary forces during their collapse, pulverizing considerable portions of the buildings' structural components and exposing first responders and civilians to substantial amounts of airborne particulate matter. Fires burned continuously under the debris until mid-December 2001. Because of ongoing fire activity and the large numbers of civilians and rescue workers who were killed during the attacks, approximately 11,000 FDNY firefighters and many emergency medical service (EMS) personnel worked on or directly adjacent to the rubble and incurred substantial exposures (Figure). This report describes morbidity and mortality in FDNY rescue workers during the 11-month period after the WTC attacks and documents a substantial increase in respiratory and stress-related illness compared with the time period before the WTC attacks. These findings demonstrate the need to provide acute and long-term medical monitoring, treatment, and counseling to FDNY rescue workers exposed to this disaster and to solve supply, compliance, and supervision problems so that respiratory protection can be rapidly provided at future disasters.

During the collapse, 343 FDNY rescue workers died and, during the next 24 hours, an additional 240 FDNY rescue workers sought emergency medical treatment. This report includes all reported injuries/illnesses during the 24 hours following the attacks. Traumatic injuries are reported for the 3 months after the attacks because many workers did not report their injuries initially so they could participate in the rescue effort. Respiratory and stress-related illnesses are reported for the 11 months after the attacks because onset might be delayed and/or influenced by repeated exposures. Stress-related illnesses include post-traumatic stress disorders, depression, anxiety disorders, and bereavement issues. Incidence rates after the attacks (September 11, 2001--August 22, 2002) are compared with rates for the preceding year (September 11, 2000--August 22, 2001). Cases were identified from the FDNY-BHS computerized medical data base, which includes data on all FDNY rescue workers who present to hospitals or treatment centers for emergency medical treatment or to FDNY--BHS for symptom/injury/illness evaluation, medical leave evaluations, the WTC exposure medical monitoring program, worker's compensation injury/illness claims, or disability/retirement evaluations. Typically, case ascertainment is complete because all FDNY rescue workers must report to FDNY--BHS for regular evaluations if they present to hospitals or treatment centers while on duty, require on- or off-duty medical leave, file worker's compensation, or request retirement disability.

The First 24 Hours Following the WTC Attacks

At the time of the attacks, 11,336 firefighters and 2,908 EMS workers were employed by FDNY. During the collapse, 343 FDNY rescue workers died (341 firefighters and two paramedics). During the first 24 hours, 240 FDNY rescue workers (158 firefighters and 82 EMS workers) sought emergency medical treatment (Table). Most (63%) were for eye irritation, respiratory tract irritation and exposure (any combination of mild exhaustion, dehydration, and eye and respiratory tract irritation) not requiring hospital admission. Of 28 FDNY rescue workers who required hospitalization, 24 had traumatic injuries including 17 with fractures, four with back trauma, two with knee meniscus tears, and one with facial burns (Table). One firefighter suffered a cervical spine fracture requiring surgery for stabilization and recovered without neurologic sequelae. Three FDNY rescue workers required hospital admission for life-threatening inhalation injuries. Eight FDNY rescue workers were evaluated for chest pain, and one EMS worker was admitted for suspected myocardial infarction; after evaluation, none was found to have coronary artery disease.

Traumatic Injuries During the 3 Months After the Attacks (September 11--December 10, 2001)

Data for the first month following the attacks include those injuries occurring in the first 24 hours that resulted in medical leave. Compared with monthly mean incidence rates for the 9 months before the attacks, the incidence of crush injuries, lacerations, and fractures during the month after the attacks increased by 200% (from three to nine), 35% (from 37 to 50), and 29% (from 21 to 27), respectively, but then returned to levels similar to those observed before the attacks. Compared with the 9 months before the WTC attacks, monthly mean incidence decreased for contusions (from 86 to 67 [29%]), sprains and strains (from 364 to 200 [41%]), other orthopedic injuries (from 96 to 61 [35%]), and burns (from 43 to three [95%]). As of August 28, 2002, a total of 90 FDNY rescue workers were on medical leave or light duty assignments because of orthopedic injuries reported during the 3 months of activity at the WTC site.

Respiratory Illnesses During the 11 Months After the Attacks (September 11, 2001--August 22, 2002)

During the 48 hours after the attacks, approximately 90% of 10,116 FDNY rescue workers evaluated at the WTC site reported an acute cough often accompanied by nasal congestion, chest tightness, or chest burning; only three FDNY rescue workers required hospitalization. Compared with numbers of service-connected, respiratory medical leave incidents (n=393) during the 11 months preceding the attacks, the number of respiratory medical leave incidents (n=1,876) increased five-fold during the 11 months after the attacks. During February 2002, the incidence of new respiratory illness requiring either medical leave or light duty began to decrease and during May 2002 began to approach pre-attack incidence.

Respiratory illness with chest radiograph abnormalities: Two weeks after the attacks, one FDNY firefighter was admitted with acute eosinophilic pneumonia after repeated exposure to WTC dust (1). The firefighter fully recovered after a short course of corticosteroid treatment. In the 3 months after the attacks, 13 FDNY firefighters were treated for pneumonia (lobar consolidation with leukocytosis) with complete resolution following antibiotic therapy. This incidence was similar to that observed for the same period 1 year earlier. As of August 28, 2002, all 14 firefighters are asymptomatic and have returned to full duties.

WTC-related cough: During the 6 months after the attacks, 332 firefighters and one EMS worker had WTC-related cough severe enough to require >4 consecutive weeks of medical leave (2). Despite treatment of upper and lower aero-digestive tract irritation (i.e., sinusitis, gastroesophageal acid reflux, and/or asthma), 173 (52%) of 333 have shown only partial improvement of WTC-related cough and remain either on medical leave or light duty or are pending a disability retirement evaluation.

As of August 28, 2002, a total of 358 firefighters and five EMS workers remained on medical leave or light duty assignment because of respiratory illness that occurred after WTC exposure. On the basis of applications for respiratory disability retirement benefits during the preceding 6 months, an estimated 500 FDNY firefighters (4% of the 11,336 total FDNY firefighter workforce) might eventually qualify for disability retirement because of persistent respiratory conditions.

Stress-Related Illnesses During the 11 Months After the Attacks (September 11, 2001--August 22, 2002)

During the 11 months after the attacks, 1,277 stress-related incidents were observed among FDNY rescue workers, a 17-fold increase compared with the 75 stress-related incidents reported during the 11 months preceding the attacks. As of August 28, 2002, a total of 250 FDNY rescue workers remain on leave with service-connected, stress-related problems. Of these, 37 also have respiratory problems.

Reported by: G Banauch, MD, M McLaughlin, R Hirschhorn, M Corrigan, K Kelly, MD, D Prezant, MD, Bur of Health Svcs, New York City Fire Dept.

Editorial Note:

During the 3 months after the WTC attacks, medical leave incidents were increased for eye irritations, fractures, crush injuries, and lacerations but decreased for other traumatic injuries. These findings probably resulted from 1) lack of adequate eye protection against fine airborne particles, 2) inability of work gloves to reduce injuries while maintaining comfort and dexterity, 3) effective use of thermal personal protective equipment despite an extremely hazardous environment, 4) prevention of major injuries because of safe work practices, and 5) underreporting of minor injuries because of the dedication of this workforce to remain on the job at the WTC site.

Although approximately 90% of FDNY rescue workers reported a new or worsening cough during the 48 hours after the attacks, only three FDNY rescue workers required hospitalization for acute inhalation injury, and no FDNY rescue worker with chest pain had coronary artery disease. These findings are related to FDNY medical policy that does not allow firefighters to perform fire-fighting duties unless cardiopulmonary function is normal. During the 11 months after the WTC attacks, the number of medical leave incidents for respiratory illnesses increased, and approximately 500 FDNY firefighters might qualify for retirement disability benefits for new onset asthma and other reactive airway diseases. Increased bronchial responsiveness also has been found in firefighters with WTC-related cough. These findings might reflect delayed or progressive inflammation of the respiratory tract with or without repeated exposures and the synergistic inflammatory effects of sinusitis and/or gastroesophageal reflux.

The high incidence of respiratory problems and related medical leave among FDNY rescue workers demonstrates the need for adequate respiratory protection. During the collapse, 52% of workers did not wear respirators, and 38% did not wear respirators for the rest of the first day (3). In addition, most of those reporting the use of a respirator during the first day used only a disposable paper dust mask that was neither NIOSH-certified nor fit-tested. However, despite widespread acknowledgment that rescue workers at future disasters be provided with respiratory protection as soon as possible, such plans will be successful only if barriers to use, such as supply, heat stress and discomfort, communications, training, compliance, and supervision, are resolved.

The increase in stress-related medical leave did not occur in large numbers until months after the attacks. Repeated exposures at the site and the increasing number of funerals and memorial services that firefighters attended during the next 11 months might have contributed to stress-related problems. In July 2002, new cases began to decline, but previous incidents of terrorism suggest that cases might increase after the 1-year anniversary of the attacks. Especially for stress-related problems, these numbers do not reflect the full volume of health evaluations and treatment activity because many workers report symptoms and seek treatment while remaining on full duty.

The findings in this report are subject to at least one limitation. Because of disaster conditions after the attacks, some rescue workers who presented to hospitals or treatment centers for emergency medical treatment and were treated and released without admission and never required medical leave might have remained unreported. This limitation would only apply to minor injuries.

One year after the WTC attacks, FDNY rescue workers continue to recover from orthopedic, respiratory, and stress-related problems. The findings in this report demonstrate the need to provide improved personal protective equipment (especially eye, hand, and respiratory protection) and continued medical monitoring, treatment, and counseling for all rescue workers exposed to disasters.

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