Air Today . . . Gone Tomorrow Article|
Use of Respiratory
Protection Among Responders at the World Trade Center Site
Centers for Disease Control and Prevention, Morbidity and Mortality
Weekly Report, September 11, 2002
Use of Respiratory Protection Among
Responders at the World Trade Center Site --- New York City, September 2001
The terrorist attacks on the World Trade Center (WTC) on September 11, 2001, created an
occupational health and safety challenge for New York City (NYC) firefighters and rescue
workers responding to the disaster. Immediate respiratory hazards included explosions,
fire, falling debris, and dust clouds containing particulate matter comprised of
pulverized building materials. Ongoing risks included lingering particulate matter in the
air and intermittent combustion products from initial and persistent fires beneath the
rubble pile. Because the nature and extent of exposures in disaster situations are complex
and difficult to characterize, the use of adequate personal protective equipment (PPE),
including respiratory protection, is essential in protecting the health of firefighters
and other rescue workers. During the weeks after September 11, the NYC Fire Department's
Bureau of Health Services (FDNY-BHS) and CDC's National Institute for Occupational Safety
and Health (NIOSH) organized a collaborative study to evaluate occupational hazards and
exposures for these workers, including their use of respiratory protection. This report
summarizes the results of that study, which indicate that the majority of firefighters did
not use adequate respiratory protection during the first week of the rescue/recovery
The study population consisted of the approximately 11,000 FDNY firefighters present at
the WTC site during the first week of the disaster. The cross-sectional study used a
stratified random sample of firefighters, categorized by arrival time at the WTC. The
study was conducted during October 2--5 and included a questionnaire (self-administered
through touch-screen computer), medical evaluation, spirometry, and blood/urine collection
for biomonitoring assays. The 53 questions elicited arrival time, number of days worked at
the WTC, work activities, and use of PPE (including respiratory protection) during each
day worked at the WTC during the first 2 weeks. The medical evaluation was mandatory, but
participation in the research study was voluntary and required informed consent.
The respiratory protection section of the questionnaire elicited firefighter respirator
use during each of the five time periods: during the collapse, day 1, day 2, days 3--7,
and week 2 following the collapse. The number of participants present each day was
calculated and used to generate rates of respirator use for each time period by respirator
type. Questionnaire choices included the following four types of respirators used by
firefighters, regardless of availability: 1) self-contained breathing apparatuses (used
for firefighting), 2) N95 filtering face masks (used for medical response), 3) half-face
respirators,* and 4) disposable dust/paint masks (hardware store type). The disposable
dust/paint mask might not have been a NIOSH-certified respirator.
Of 400 firefighters, 361 (91%) participated in the study; 319 had responded to the WTC
disaster, and 42 were unexposed controls. All participants were men; mean years worked as
a firefighter was 15 years (range: <1--38 years), and mean age was 42 years (range:
24--60 years). The firefighters who responded to the disaster were asked whether they were
present at the site during various time periods: 149 reported being present during the
collapse, 118 arrived later that day, 222 were present on day 2, a total of 284 were
present >1 day during days 3--7, and 231 were present during week 2.
Of those present during the WTC collapse, 67 (52%) reported wearing no respiratory
protection, and 41 (38%) of those arriving later that day wore no respirator (Figure). The
respirator most commonly used during the first day was the disposable mask; of the 130
firefighters present on the first day (either during or following the collapse) who
reported wearing a respirator, 76 (58%) used the disposable mask. During the initial
2-week period, use of half-face respirators increased, and use of the disposable masks
Reported by: D Prezant, MD, K Kelly, MD, New York City Fire Dept, Bur of Health Svcs. B
Jackson, PhD, D Peterson, PhD, RAND Science and Technology Policy Institute, Santa Monica,
California. D Feldman, MD, S Baron, MD, CA Mueller, MS, B Bernard, MD, B Lushniak, MD, Div
of Surveillance, Hazard Evaluations and Field Studies; L Smith, MS, R BerryAnn, B Hoffman,
MBA, National Personal Protective Technology Laboratory, National Institute for
Occupational Safety and Health, CDC.
Adequate planning, preparation, and training are key to protecting the safety and health
of emergency responders. Anticipating the nature and magnitude of exposures during the
initial stages of a disaster situation is difficult; however, plans should be in place to
provide a rapid emergency response and protect the health of the responders. The findings
in this report indicate that many firefighters responding to the WTC disaster were not
protected adequately during the initial stages of the emergency response.
The findings in this report are subject to at least two limitations. First, the collection
of reliable information about respirator use patterns is difficult. Some firefighters
reporting use of a respirator might not have been fit-tested adequately or might have used
it sporadically, resulting in an overestimation of the percentage of those who were
protected adequately. Second, because firefighters were asked to report daily respirator
use 3--4 weeks after the event, responses are subject to recall bias. Despite these
limitations, the general results from the questionnaire are consistent with reports by
safety experts who were present during the first few weeks of the rescue/recovery
To evaluate the availability and adequacy of PPE during disaster situations and to make
recommendations for future planning, CDC, in collaboration with the RAND Science and
Technology Policy Institute, sponsored a conference of persons with first-hand knowledge
of emergency response to terrorist attacks. The conference was held in NYC in December
2001. Attendees included persons who responded to the 1995 attack on the Alfred P. Murrah
Federal Building in Oklahoma City, the September 11 attacks on the WTC and the Pentagon,
and the anthrax incidents that occurred during fall 2001, and represented multiple
occupations and skills (e.g., firefighters, police, emergency medical technicians,
construction workers, union officials, and government representatives from local, state,
and federal agencies).
The participants discussed all aspects of a program for protection of emergency responders
including information and training, performance of particular PPE in a disaster
environment, and concerns related to adequate management of disaster sites. On the basis
of this experience, participants developed recommendations about technologies and
procedures that could help protect the health and safety of emergency workers as they
respond to acts of terrorism. The final recommendations included the following (1):
Develop guidelines for appropriate PPE ensembles for long-duration disaster responses
involving rubble, human remains, and different respiratory threats. If appropriate
equipment is not available, address barriers to its development. Such equipment could be
applicable to other major disasters (e.g., earthquakes or tornadoes) and to terrorist
Define the appropriate ensembles of PPE needed to respond safely and efficiently to
biologic incidents, threats, and false alarms. Key considerations include providing
comparable levels of protection for all responders and addressing the logistical and
decontamination concerns associated with large numbers of responses in short time periods.
Explore effective ways to outfit all responders at large incident sites with appropriate
PPE as rapidly as possible.
Examine barriers to equipment standardization or interoperability among
emergency-responder organizations. Strategies could include coordinating equipment
procurement among organizations or working with equipment manufacturers to promote broader
interoperability within classes of equipment.
Training and Information
Define mechanisms to provide responders at incident sites rapidly and effectively with
useful information about potential hazards and the equipment they need for protection.
Approaches could include more effective coordination among relevant organizations and
development of technologies that provide responders with individual, real-time information
about their environment.
Ensure that responders at large-scale disaster sites are trained appropriately to use PPE.
All responders must be trained, and mechanisms that provide training and experience with
the equipment before a disaster occurs should be investigated.
Consider logistical requirements of extended-response activities during disaster drills
and training. Such activities provide response commanders with information on logistical
constraints to response capabilities.
Provide guidelines and define organizational responsibilities for enforcing PPE use at
major disaster sites. Although such guidelines must address the risks responders are
willing to take when the potential exists to save lives, they also should reflect the
principle that the health and safety of responders should be a primary concern during
Develop mechanisms to allow rapid and efficient scene control at disaster sites as early
as possible during a response.
This report was based on data contributed by S Lenhart, MSPH, Div of Surveillance, Hazard
Evaluations and Field Studies, National Institute for Occupational Safety and Health, CDC.
1. RAND Science and Policy Institute. Protecting emergency responders: lessons learned
from terrorist attacks. Santa Monica, California: RAND Science and Policy Institute, 2002.
Available at http://www.rand.org/publications/CF/CF176.
*The half-face elastomeric reusable respirator with combination P100 and organic
vapor/acid gas cartridges were recommended by NIOSH and other agencies for WTC
rescue/recovery personnel working in debris or performing decontamination at the WTC site
(work in which surface dust was disturbed or resuspended in the air). For workers not
scheduled to work in debris, a half-face P100 or N100 respirator (either disposable or
elastomeric) was recommended; however, these were not available routinely during the
initial 48 hours.
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