Protecting the Protectors: Ensuring the Health and Safety of our First Responders in the Wake of Catastrophic Disasters

CDC Congressional Testimony

Committee on Homeland Security, United States House of Representatives

Laboratory Research Related to the FTC Method

Thursday, September 20, 2007

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 morning, Chairman Thompson and other distinguished Members of the Committee. 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). CDC′s 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.

Mr. Chairman, I would like to express my appreciation to you and to the members of the subcommittee for holding this hearing and for addressing the critical need of ensuring the health and safety of our first responders. 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 response effort after the World Trade Center (WTC) attack on 9/11 and NIOSH′s ongoing activities to protect responders in general.

Since February 2006, I have served as the HHS WTC Programs Coordinator. Secretary of Health and Human Services Michael O. Leavitt determined that there was a “critical need to ensure that programs addressing the health of WTC responders and nearby residents are well–coordinated,” and charged me with this important task. Since receiving this assignment I have traveled to New York City (NYC) and Albany, New York, to assess the status of the existing HHS programs addressing WTC health effects, and meet with those we serve. Participating in these dialogues has enabled me to better understand the needs of those affected, and the steps we can take to meet those needs. As the HHS WTC Programs Coordinator, I work to coordinate the existing programs and ensure scientific reporting to provide a better understanding of the health effects arising from the WTC attack. Today, I will focus my remarks on the progress we′ve made towards these tasks, lessons learned, and NIOSH′s efforts to address responders′ needs for future disasters.

WTC Responder Health Program – Monitoring and Treatment

Since 2002, agencies and offices within HHS have been dedicated to tracking and screening WTC rescue, recovery and clean up workers and volunteers (responders).

In 2004, NIOSH established the national WTC Worker and Volunteer Medical Monitoring Program to continue baseline screening (initiated in 2002), and provide long–term medical monitoring for WTC responders. In FY 2006, Congress appropriated $75 million to CDC to further support existing HHS WTC programs and provide screening, monitoring, and medical treatment for responders. Since these funds were appropriated, NIOSH has established a coordinated WTC Responder Health Program to provide annual screenings, as well as diagnosis and treatment for WTC–related conditions (e.g. aerodigestive, musculoskeletal, and mental health) identified during monitoring exams. The WTC Responder Health Program consists of a consortium of clinical centers and data and coordination centers that provide patient tracking, standardized clinical and mental health screening, treatment, and patient data management.

To date, the WTC Responder Health Program has screened approximately 36,000 responders. The New York City Fire Department (FDNY) manages the clinical center that serves FDNY firefighters who worked at Ground Zero. As of July 31, 2007, FDNY had conducted 29,203 screenings, including 14,429 initial examinations and 14,774 follow–up examinations. The Mt. Sinai School of Medicine′s Center for Occupational and Environmental Medicine coordinates a consortium of clinics that serve other response workers and volunteers who were active in the WTC rescue and recovery efforts. These clinics have conducted 21,088 initial examinations and 9,101 follow up examinations. Of the 36,000 responders in the WTC Responder Health Program, 7,603 have received treatment for aerodigestive conditions, such as asthma, interstitial lung disease, chronic cough, and gastro–esophageal reflux, and 4,868 have been treated for mental health conditions.

The availability of treatment for both physical and mental WTC–related health conditions has encouraged more responders to enroll and continue participating in the WTC Responder Health Program, which will enable us to better understand and treat the long–term effects of their WTC exposures.

WTC Federal Responder Screening Program

In FY 2002, the HHS Office of Public Health Emergency Preparedness – which is now the Office of the Assistant Secretary for Preparedness and Response (ASPR) – received $3.74 million through Federal Emergency Management Agency (FEMA) to establish the WTC Federal Responder Screening Program to provide medical screening for all Federal employees who were involved in the rescue, recovery or clean up efforts. Current Federal employees in this program are screened by the HHS Federal Occupational Health (FOH), a service unit within HHS. FOH has clinics located in areas where large numbers of Federal workers are employed. As of August 31, 2007, FOH had screened 1,331 Federal responders. In February 2006, CDC–NIOSH and OPHEP (now ASPR) signed a Memorandum of Understanding to monitor former Federal workers via the WTC Responder Health Program. Since then, former Federal workers have been enrolled in the WTC Responder Health Program and served by the Mt. Sinai Data and Coordination Center and national clinic partners.

Nationwide Scope

HHS is working with its partners to ensure that the benefits of all federally–funded programs are available to all responders, across the nation. Those responders who selflessly came to the rescue of NYC from throughout the country to assist in rescue efforts at the time of the WTC disaster should receive the same high quality monitoring and treatment as those who reside in the NYC Metropolitan Area. Enrollees in the WTC Responder Health Program who are not located in the NYC Metropolitan Area, receive monitoring and treatment via a national network of clinics managed by QTC, Inc. and the Association of Occupational and Environmental Clinics (AOEC), respectively. To date, 698 responders outside of the NY Metropolitan Area have been screened by the WTC Responder Health Program.

Achieving such nationwide coverage for WTC responders is challenging; however, we are committed to serving all responders, regardless of their location or employment status. I am actively working with the medical directors of the WTC Health Program, the WTC Federal Responder Screening Program, QTC, Inc. and AOEC to ensure that the services available to responders are uniform across programs.

WTC Health Registry

In addition to the WTC Responder Health Program, the Agency for Toxic Substances and Disease Registry (ATSDR) maintains the World Trade Center Health Registry. In 2003, ATSDR, in collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), established the WTC Health 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.

WTC Health Registry registrants will be interviewed periodically through the use of a comprehensive and confidential health survey to assess their physical and mental health. At the conclusion of baseline data collection in November 2004, 71,437 interviews had been completed, establishing the WTC Health Registry as the largest health registry of its kind in the United States. The Registry findings provide an important picture of the long–term health consequences of the events of September 11th. Registry data are used to identify trends in physical and mental health resulting from the exposure of nearby residents, school children and workers to WTC dust, smoke and debris.

The WTC Health Registry also serves as a resource for future investigations, including epidemiological, population specific, and other research studies, concerning the health consequences of exposed persons. These studies can assist those working in disaster planning who are proposing monitoring and treatment programs by focusing their attention on the adverse health effects of airborne exposures and the short– and long–term needs of those who are exposed. The findings will permit us to develop and disseminate important prevention and public policy information for use in the unfortunate event of future disasters.

Since 9/11, HHS has worked diligently with our partners to best serve those who served their country, as well as those in nearby communities affected by the tragic attack. While we have made much progress, we must continue to gather and analyze data that will enable us to better understand the health effects we have observed.


I want to reaffirm the Department′s commitment to work with the Congress to provide compassionate and appropriate help to responders affected by the World Trade Center exposures following the attacks.

As you know, the Department of Defense, Emergency Supplemental Appropriations to Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act of 2006 (P.L. 109–148) provided $75 million for the treatment, screening, and monitoring of the responders. With less than one month remaining in the fiscal year (FY) we are confident this funding will last at least until the end of FY 2007.

The President′s FY 2008 budget requests $25 million for World Trade Center responders and in May 2007, the President signed the U.S. Troop Readiness, Veterans′ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007 (P.L. 110–128), which included an additional $50 million to support continued treatment and monitoring for World Trade Center responders. This funding will be awarded, as needed, to support continued monitoring, care, and treatment of responders through FY 2008.

From July 1, 2006, through June 30, 2007, the Federal grantees have reported to NIOSH spending approximately $15 million total for treatment for World Trade Center related illnesses. This includes $6 million from American Red Cross funds and $9 million from the $42 million total Federal grants awarded in October 2006. Of this $9 million, the grantees have actually “drawn down” only $2 million in payments on the Federal grants.

Over $90 million in appropriated funds remains available – including the balance of the treatment funds appropriated in FY 2006 and the $50 million appropriated in FY 2007 – before adding the $25 million included in the President′s FY 2008 budget request. HHS is gathering additional financial data from the Federal grantees in order to better understand the healthcare cost issues of the responders. Additional data will help inform our policies, ensure that the current program operates efficiently and effectively, and maximize the available resources to meet responders′ medical needs. HHS will continue to monitor the work of the grantees as part of the FY 2009 budget process.

Lessons Learned

In December 2001, NIOSH convened a conference to explore lessons about preserving the safety and health of emergency responders in the context of terrorist attacks, organized and led by the RAND Science and Technology Policy Institute in New York City. This conference and subsequent evaluations of response efforts to large–scale disasters concluded that there is a critical need for:

  • Accessibility to protective and practical personal protective equipment (PPE) and hazard monitoring technologies;
  • Interagency training to aid in the effective implementation of health and safety measures and PPE enforcement;
  • Quick and effective establishment of a command authority over the disaster site and perimeter control; and
  • Tracking of responders.

In my experience as WTC Health Coordinator, I have learned that we must address responder safety and health in three stages: pre–deployment, deployment and post–deployment. During the pre–deployment stage, prior to the initiation of a response, all responders need to be adequately trained to recognize and protect themselves from health and safety hazards. Adequate preparation is especially important for spontaneous or unaffiliated responders who volunteer their services. As reported in findings based on WTC Health Registry data, these responders are often more adversely affected, possibly due to a lack of health and safety training (American Journal of Psychiatry, 2007; 164; 1385–1394). During the deployment stage, when responders are actively engaged in the response effort, it is critical to track responders′ access to the disaster site and conduct real–time exposure assessment. Knowing where responders have gone and their potential exposures will enable us to more accurately assess their health effects and determine their post–deployment needs. During post–deployment, once the response effort is completed, responders should be screened for health (physical and emotional) effects, if exposure assessment or the occurrence of symptoms indicates. These findings could then be used to determine if long–term monitoring and treatment are necessary. To ensure responder safety and health during future disaster events, we must address each of these stages.

Additional NIOSH Programs

In addition to WTC–related programs, NIOSH continues to conduct research and make recommendations to protect the health and safety of first responders and recovery workers through various program activities.

In the aftermath of disasters, NIOSH actively participates in the response effort and identifies staff to provide technical expertise to meet immediate worker protection needs. As outlined by the Worker Safety and Health Annex of the National Response Plan, NIOSH provides assistance on occupational exposure assessments, provides guidance on personal protective equipment, and develops and disseminates guidelines to integrate worker safety and health into site operations. NIOSH works with multidisciplinary occupational safety and health teams to develop procedures for follow–up evaluations of worker injuries, conduct health hazard evaluations (HHEs) and provide technical assistance to local, state, and Federal governmental agencies to assess potential health effects from workers′ exposures in the recovery zone.

NIOSH also conducts research to address the critical need for effective personal protective technologies, such as respirators, chemical–resistant clothing, hearing protectors, and safety goggles and glasses that provide a barrier between the worker and an occupational safety or health risk. Building upon NIOSH′s longstanding respiratory certification and evaluation program for respirators used in traditional work settings, NIOSH scientists test and approve respirators for use by responders against chemical, biological, radiological, and nuclear (CBRN) agents. Since 9/11, NIOSH has approved 77 different models of CBRN respirators. Our work has led to an increase in the national inventory of respiratory protection equipment and supports the long–term development of standards and technologies for protecting the health and safety of workers, especially first responders.

NIOSH addresses hazards specific to fire fighters through the Fire Fighter Fatality Investigation and Prevention Program. Through this program NIOSH conducts in–depth evaluations of fire fighter line–of–duty deaths to formulate recommendations for preventing future deaths and injuries. The goals of the program are to: better define the characteristics of line–of–duty deaths among fire fighters, develop recommendations for the prevention of deaths and injuries, and disseminate prevention strategies to the fire service.

Additionally, NIOSH has developed an aggressive Research Portfolio to address a wide range of research needs in the emergency response community. Examples of proposed research include developing tools to improve safety climate, advances in personal protective equipment, enhanced medical surveillance methods for responders and recovery workers, and advancing environmental sampling strategies.

NIOSH is committed to protecting the health and safety of workers, and is actively working to address the critical needs of first responders. I appreciate your support of our efforts and look forward to working with you in the future as we continue to serve this deserving population. Thank you for the opportunity to testify. I would be happy to answer any questions you may have.

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