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Robin Herbert,¹ Jacqueline Moline,¹ Gwen Skloot,² Kristina Metzger,¹ Sherry Baron,³ Benjamin Luft,⁴ Steven Markowitz,⁵ Iris Udasin,⁶ Denise Harrison,⁷ Diane Stein,¹ Andrew Todd,¹ Paul Enright,⁸ Jeanne Mager Stellman,^1,9 Philip J. Landrigan,¹ and Stephen M. Levin¹

¹Department of Community and Preventive Medicine, and ²Division of Pulmonary, Critical Care & Sleep Medicine, Mount Sinai School of Medicine, New York, New York, USA; ³Division of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA; ⁴Department of Medicine, State University of New York at Stony Brook, Port Jefferson, New York, USA; ⁵Center for Biology of Natural Systems, Queens College, Flushing, New York, USA; ⁶Environmental and Occupational Health Sciences Institute, University of Medicine & Dentistry of New Jersey, Piscataway, New Jersey, USA; ⁷Department of Environmental Medicine, Bellevue Hospital Center/New York University School of Medicine, New York, New York, USA; ⁸Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA; ⁹Mailman School of Public Health, Columbia University, New York, New York, USA

Abstract
Background: Approximately 40,000 rescue and recovery workers were exposed to caustic dust and toxic pollutants following the 11 September 2001 attacks on the World Trade Center (WTC) . These workers included traditional first responders, such as firefighters and police, and a diverse population of construction, utility, and public sector workers.

Methods: To characterize WTC-related health effects, the WTC Worker and Volunteer Medical Screening Program was established. This multicenter clinical program provides free standardized examinations to responders. Examinations include medical, mental health, and exposure assessment questionnaires ; physical examinations ; spirometry ; and chest X rays.

Results: Of 9,442 responders examined between July 2002 and April 2004, 69% reported new or worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of examination in 59% of these workers. Among those who had been asymptomatic before September 11, 61% developed respiratory symptoms while performing WTC work. Twenty-eight percent had abnormal spirometry ; forced vital capacity (FVC) was low in 21% ; and obstruction was present in 5%. Among nonsmokers, 27% had abnormal spirometry compared with 13% in the general U.S. population. Prevalence of low FVC among nonsmokers was 5-fold greater than in the U.S. population (20% vs. 4%) . Respiratory symptoms and spirometry abnormalities were significantly associated with early arrival at the site.

Conclusion: WTC responders had exposure-related increases in respiratory symptoms and pulmonary function test abnormalities that persisted up to 2.5 years after the attacks. Long-term medical monitoring is required to track persistence of these abnormalities and identify late effects, including possible malignancies. Lessons learned should guide future responses to civil disasters.

Key words: air pollution, disaster response, occupational lung disease, pulmonary function, September 11, spirometry, World Trade Center. Environ Health Perspect 114: 1853–1858 (2006) . doi:10.1289/ehp.9592 available via http://dx.doi.org/ [Online 6 September 2006]

Address correspondence to R. Herbert, Department of Community and Preventive Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1057, New York, NY 10029 USA. Telephone: (212) 241-5664. Fax: (212) 824-9015. E-mail: robin.herbert@mssm.edu

We thank S. Carroll, S. Jiang, E. Jurgel, H. Juman-James, C. Katz, K. Kirkland, P. Landsbergis, K. Leitson, B. Newman, N. Nguyen, R. Smith, L. Stevenson, J. Weiner, other staff and patients of the World Trade Center Worker and Volunteer Medical Screening Program (MSP) , and labor, community, and volunteer organizations for their contributions to this article and their involvement with the MSP. We especially thank the American Red Cross Liberty Fund, The September 11^th Recovery Program, The Bear Stearns Charitable Foundation, The September 11^th Fund, The Robin Hood Foundation Relief Fund, and many others.

This work was supported by the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health, contract 200-2002-0038 and grant 5U1O 0H008232.

The authors declare they have no competing financial interests.

Received 9 August 2006 ; accepted 5 September 2006.