Progress Since 9/11: Protecting Public Health and Safety Against Terrorist Attacks

CDC Congressional Testimony

Committee on on National Security, Emerging Threats, and International Relations, Committee on Government Reform, United States House of Representatives

Statement of:
John Howard, M.D., M.P.H.
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Good afternoon Mr. Chairman and other distinguished members of the Subcommittee. My name is John Howard, and I am the Director of the National Institute for Occupational Safety and Health (NIOSH), which is part of the Centers for Disease Control and Prevention (CDC) within the Department of Health and Human Services (HHS). CDCs mission is to promote health and quality of life by preventing and controlling disease, injury and disability. NIOSH is a research institute within CDC that is responsible for conducting research and making recommendations to identify and prevent work-related illness and injury. I am pleased to appear before you today to report on the progress we have made in addressing the health needs of those who served in the rescue and recovery effort after the World Trade Center (WTC) attack on 9/11.

The WTC attack of 2001 was tragic and has indelibly changed the face of public health. The philosophy of public health during the 20th century was to prevent naturally occurring outbreaks and injuries. However, in the 21st Century the health and security of the United States also depends on our preparedness against terrorism. The health and security of the United States also depends on our preparedness against terrorism, capacity to handle large-scale emergency response, and ability to address the long-term needs of affected populations.

In response to the WTC attacks, CDC responded immediately to assist the victims, and the workers and volunteers who selflessly answered the call for help in the nations time of need. Today, we remain committed to meeting the health needs of our nations heroes. I will focus my remarks on the progress being made in addressing the potential short-and long-term health effects experienced by workers and volunteers due to their exposures to the WTC site. I will report on the status of programs in place for monitoring health and our plans for providing continued assistance.

Mr. Chairman, I would like to express my appreciation to you and to the members of the subcommittee for holding this hearing. CDC shares your concern for the community and for the health of the brave men and women who worked tirelessly in the rescue and recovery efforts at Ground Zero.

Baseline and Long-term Medical Monitoring

Firefighters, Non-Federal Workers and Volunteers

As previously reported to the Subcommittee, studies conducted by the National Institutes of Health (NIH) and CDC-NIOSH at Ground Zero found that rescue and recovery workers were being exposed to airborne contaminants, psychological stressors, and physical hazards and were at risk for job-related injury and illness. In response, CDC established programs to identify the affected population and conduct baseline medical evaluations.

In 2002, Congress provided funding through FEMA for the baseline health monitoring of WTC responders. CDC partnered with the New York City Fire Department, New York State Department of Health and Mt. Sinai School of Medicines Center for Occupational and Environmental Medicine to conduct baseline medical screenings of WTC responders.The symptoms identified in the screenings, such as the World Trade Center Cough, prompted the development of specialized medical monitoring programs to assess the long-term effects of Ground Zero exposure. To assess the long term health effects experienced by New York City firefighters and other rescue, recovery and restoration workers and volunteers not covered by other monitoring programs, CDC-NIOSH established the national WTC Worker and Volunteer Medical Monitoring Program (WTC Medical Monitoring Program). This program consists of a consortium of clinical centers and data and coordination centers that provide patient tracking, standardized clinical and mental health screening, patient data management and clinical referral services.

The New York City Fire Department (FDNY) manages the clinical center and data and coordinating center that monitor the unique health and exposure characteristics experienced by FDNY firefighters working at Ground Zero. Mt. Sinai School of Medicines Center for Occupational and Environmental Medicine is the data and coordinating center for the five clinical centers which serve other response workers and volunteers in the New York metropolitan area. To serve responders who live outside the New York metropolitan area, Mt. Sinai collaborates with various community and private physicians across the nation.

Since 2002, the WTC Medical Monitoring Program has served more than 30,000 responders. As of February 2, 2006, FDNY has conducted 19,149 screenings, including 15,284 initial examinations and 3,865 follow up examinations. Likewise, the clinical centers coordinated by Mt. Sinai have conducted 19,521 screenings, including 14,995 initial examinations and 4,526 follow-up examinations.

The initial screening protocol used by the clinical centers focused on providing a thorough assessment of the effects of Ground Zero exposure on physical health. However, being on the frontlines of the WTC response effort also has had serious consequences on mental health. In response to reports, clinical observations, and recommendations made by partner organizations and the WTC Steering Committee (17 members representing labor organizations and the WTC clinical and data and coordination centers), the WTC Medical Monitoring Program incorporated a more robust mental health component in the screening protocol in late 2004. With this addition to the protocol, we are taking a more comprehensive, holistic approach to assessing the health effects experienced by responders.

The data and coordination centers of the WTC Medical Monitoring Program regularly analyze the medical reports provided by the clinical centers.Their findings will help define the long term health care needs for the responder population, and will also provide important information on the consequences of air pollutants, physical stressors, emotional stress, musculoskeletal exertions and other occupational and environmental exposures.Findings from a subset of WTC Medical Monitoring Program participants were published in the CDC Morbidity and Mortality Weekly Report (MMWR), September 10, 2004 [53(35); 807-812]. The MMWR notes that the majority of WTC responders participating in the program reported experiencing upper and lower respiratory symptoms including shortness of breath, sinus congestion and irritation that persisted after all WTC response work was stopped. The workers and volunteers also reported musculoskeletal and gastrointestinal symptoms.These trends continue to be reported in 2005 and 2006 and highlight the need for a long term health monitoring program.CDC-NIOSH remains committed to providing the services needed.

Current and Former Federal Workers

In early 2002, the HHS Office of Emergency Preparedness (later OPHEP) agreed that Federal workers with official WTC response duties would be screened by the Federal Occupational Health Service (FOH) using funds provided by the Federal Emergency Management Agency (FEMA).

In March 2003, the Federal Emergency Management Agency (FEMA) and HHS Office of Emergency Preparedness (later OPHEP) completed an interagency agreement (IAA) allocating $3.7 million for the specific purpose of conducting baseline medical screening for Federal responders.

FOH began conducting screenings in June 2003. Approximately six months after the program began, FOH halted the screening process because they too identified the need for more robust mental health screening protocols and other diagnostic tests and the need to have a referral mechanism for health concerns that were identified. In addition, it became necessary to identify authority to provide services to former Federal employees, including retirees and those who were federal employees solely for purposes of the WTC response effort (i.e., “federalized” workers).

In response to these issues OPHEP and FOH modified the IAA in July 2005 to include further diagnostic testing and a referral process.Since the FOH mission precluded them from conducting screening for former Federal workers, the decision was made to contract with the CDC-NIOSH WTC Medical Monitoring Program to provide baseline screening for former Federal employees, including retirees and workers who were federalized solelyfor the WTC response effort. To inform the numerous Federal agencies participating in the response activities of the services available to Federal responders, OPHEP entered into an IAA with the Agency for Toxic Substances and Disease Registry (ATSDR) in April 2005 to identify and contact all Federal WTC responders and to provide program and registration information.

To date, of the $3.7M allocated for this program, $2.2M has been obligated to FOH for the purpose of screening current Federal employees and to ATSDR for the purpose of outreach and registration management. The remaining funds will be obligated to CDC-NIOSH for the purpose of screening former Federal employees.

Since restarting the program, 135 Federal agencies have been contacted and approximately 1,700 individual federal responders have been identified. Of those responders identified, 423 current, 40 former and 12 retired Federal employees have registered for screening. Of the registered Federal responders, 166 have been screened and 250 have been scheduled for screening appointments.

Development of a Treatment Program

To ensure the continued screening and treatment of WTC responders, Congress appropriated $75 million to CDC in the fiscal year 2006 Defense Appropriations bill. A portion of these funds will be used to establish a WTC responder treatment program. Currently, WTC responders examined in the screening and monitoring program are referred to the Red Cross WTC Health Effects Treatment Program for follow-up care. However, this program is projected to end in 2007. To ensure the availability of treatment services, CDC-NIOSH is working with the Red Cross to establish a new outpatient treatment program that will serve as an extension of the existing WTC Medical Monitoring Program. This collaboration will enable us to structure a program that will seamlessly provide the full gamut of medical care WTC responders need and deserve.Establishing a national treatment program is a new venture for CDC-NIOSH; however, we are diligently working with the Red Cross, WTC Medical Monitoring Program and WTC Steering Committee to effectively meet the needs of WTC response workers and volunteers.

As directed by the legislation, CDC will also use the newly appropriated funds to support existing programs providing WTC responders with needed services. Increased costs resulting from the recent expansion of the protocol to include a comprehensive mental health assessment and the increase in outreach efforts necessary to inform participants of the services provided by the program may make it necessary to use a portion of these funds to supplement the WTC Medical Monitoring Program. The funds initially appropriated for this program in 2003 are available through 2009.

CDC will also use the recent appropriation to fund programs addressing unique needs identified by the WTC responder community, such as the New York City Police Foundation Project COPE and the Police Organization Providing Peer Assistance (POPPA).These programs provide traditional mental health services and peer counseling, respectively, for police officers who assisted in WTC rescue and recovery efforts. CDC-NIOSH has met with these partner organizations to discuss the valuable services they offer, and will continue to communicate with these groups as funding decisions are finalized.

World Trade Center Health Registry (WTCHR)

In addition, a portion of the appropriated funds will be directed to support the WTC Health Registry (WTCHR).ATSDR, in collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), established a registry to identify and track the long term health effects of tens of thousands of residents, school children and workers (located in the vicinity of the WTC collapse, as well as those participating in the response effort) who were the most directly exposed to smoke, dust, and debris resulting from the WTC collapse. The WTCHR began baseline data collection on September 5, 2003 and finished on November 20, 2004.The Registry will be maintained over time by the NYCDOHMH.

At the conclusion of baseline data collection, 71,437 interviews were completed, establishing the WTCHR as the largest health registry of its kind in the United States.Registrants include people from each of the 50 states and 12 foreign nations.Participation in the health registry is voluntary and stringent safeguards are in place to protect the confidentiality of all information collected.  Fostering a cross Federal agency effort, both FEMA and EPA have provided funding to ATSDR for various aspects of the development, and maintenance of the WTC Health Registry.

The WTC Health Registry is beginning to provide an important picture of the long term health consequences of the events of September 11th. Registry information will be used to identify trends in physical or mental health resulting from the exposure of nearby residents, school children and workers to WTC dust, smoke and debris. Findings suggest that WTCHR enrollees experienced higher levels of psychological distress than found in the general New York City adult population. Health outcome data resulting from preliminary analyses of Registry data demonstrate that nearly half of adult enrollees reported new or worsened sinus and nasal problems after September 11th. Other common respiratory complaints included shortness of breath, wheezing, persistent cough and throat irritation. One in four enrollees reported new or worsened heartburn, indigestion or reflux symptoms. Registrants will be interviewed periodically over a period of 20 years or more through the use of a comprehensive and confidential health survey concerning their physical and mental health. The first coordinated follow-up interviews of the 71,437 participants are scheduled to begin in March 2006. Data collection for the first follow-up interview is expected to last until September 2006.

By assembling a broad range of data and information into a single database, the Registry facilitates coordinated follow-up activities.WTCHR will serve as a resource for future investigations, including epidemiological and other research studies, concerning the health consequences of exposed persons. These investigations and studies will act as a significant base for developing and disseminating important prevention and public policy information for use in the unfortunate event of future disasters. The NYCDOHMH and ATSDR will continue to analyze registrant data concerning physical or mental health impacts and communicate this information to the public and health care providers so those affected can make informed decisions about their health. Information is posted quarterly and available on the WTC Health Registry Website (

Lessons Learned, Responding to Future Attacks

Four years have passed since the tragic attacks of 9/11 – as we reflect on the tragedy, we must also reflect on what we have learned.In order to protect the public from the threats of today, our public health and health care systems must be poised to respond with greater flexibility, speed and capacity. We must be able to immediately respond to a wide range of public health emergencies, as well as provide the long term care that may be needed.

Having established a screening and monitoring program to address the health needs of WTC responders, CDC is better equipped to assess the health effects of workers and volunteers responding to a large scale disaster. We have a standardized clinical protocol that may used to conduct baseline and long-term examinations and the framework for developing a national monitoring program to serve affected populations. Our recent efforts to establish a treatment program will also provide a valuable addition to our emergency response toolkit. We are working hard to meet the public health challenges of the 21st century, and remain committed to the health and welfare of men and women who selflessly served on the front-line of the WTC response.

Thank you for your attention. I am pleased to answer any questions.

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