title: Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort.
abstract: BACKGROUND
  The Sept 11, 2001 (9/11) World Trade Center (WTC) disaster has been associated with several subacute and chronic health effects, but whether excess mortality after 9/11 has occurred is unknown. We tested whether excess mortality has occurred in people exposed to the WTC disaster.
  
  
  METHODS
  In this observational cohort study, deaths occurring in 2003-09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. Eligible participants were rescue and recovery workers and volunteers; lower Manhattan area residents, workers, school staff and students; and commuters and passers-by on 9/11. Study participants were categorised as rescue and recovery workers (including volunteers), or non-rescue and non-recovery participants. Standardised mortality ratios (SMR) were calculated with New York City rates from 2000-09 as the reference. Within the cohort, proportional hazards were used to examine the relation between a three-tiered WTC-related exposure level (high, intermediate, or low) and total mortality.
  
  
  RESULTS
  We identified 156 deaths in 13,337 rescue and recovery workers and 634 deaths in 28,593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38-0·53) and non-rescue and non-recovery participants (0·61, 0·56-0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1·22, 95% CI 1·01-1·48, for intermediate exposure and 1·56, 1·15-2·12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart-disease-related mortality (adjusted hazard ratio 2·06, 1·10-3·86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56-2·78, for high exposure and 1·03, 0·52-2·06, for intermediate exposure when compared with low exposure).
  
  
  CONCLUSIONS
  This exploratory study of mortality in a well defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants.
  
  
  BACKGROUND
  US Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health, Agency for Toxic Substances and Disease Registry, and National Center for Environmental Health); New York City Department of Health and Mental Hygiene.
authors: New York City Department of Health and Mental Hygiene, Long Island City, NY 11101, USA.
authors: Hannah T
authors: HT
authors: Jordan
authors: Robert M
authors: RM
authors: Brackbill
authors: James E
authors: JE
authors: Cone
authors: Indira
authors: I
authors: Debchoudhury
authors: Mark R
authors: MR
authors: Farfel
authors: Carolyn M
authors: CM
authors: Greene
authors: James L
authors: JL
authors: Hadler
authors: Joseph
authors: J
authors: Kennedy
authors: Jiehui
authors: J
authors: Li
authors: Jonathan
authors: J
authors: Liff
authors: Leslie
authors: L
authors: Stayner
authors: Steven D
authors: SD
authors: Stellman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000397:Air Pollution / Q000009:adverse effects; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D019337:Hematologic Neoplasms / Q000401:mortality; D006801:Humans; D007223:Infant; D008297:Male; D001523:Mental Disorders / Q000401:mortality; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality; D009519:New York City / Q000453:epidemiology; D016016:Proportional Hazards Models; D012042:Registries; D018635:Rescue Work; D012140:Respiratory Tract Diseases / Q000401:mortality; D047851:September 11 Terrorist Attacks / Q000706:statistics & numerical data*; D017741:Survivors; D055815:Young Adult