World Trade Center Disaster Response

New York City Department of Health

Day 7: 9/17/01 (Monday)
8am-8pm Summary
COMMAND CENTER AND OEM OPERATIONS
General issues - OK to staff evenings/nights with signout person
Meetings today at 12 noon and 5 pm, instead of 9 am, 12 am, and 6 pm
Kelly and Jim are coordinating with federal resources

I. Environmental Workgroup
Occupational Health and Safety Plan for worker safety at site
Strategy group this morning put together plan for Personal Protective Equipment
(see attachment)
Gloves - where people wearing cloth gloves (need to right up as recommendation)
Will re-update recommendations for workers to add gloves, when your cartridge is
gone, etc. (need this attachment)
Keep Kelly and Jim up to date about what our recommendations are

OEM is making health and safety plan today (trying to fax over)

Respirators - unclear what inventories are, where they are, what type
Some teams at unknown sites have respirators, such as forestry teams
Need to have system for inventory and maintaining supplies
Shortage of masks developed today, lots of turnover
Ordered 11,000 masks and 23,000 combo cartridges, DCAS doing purchase
Who does distribution of respirators?

Fit testing - one team (MD, RN, PHA, clerical) to each site, with four industrial
hygienists to instruct our team
Credentialing of teams, one pager on how to use respirator
4 sites, AMEX, others
Need to reassess needs, and create schedule for fit testing through next Monday
No follow up for lead issues required

Air quality
What is plan for air monitoring, with fixed sites? - 2 pm meeting today to discuss
EPA will come up with sampling plan, need more community monitoring
125 Worth, BMCC, Battery Park, need access to buildings to do air monitoring
Group process with EPA about monitoring, DOH receiving results
Some areas are above 0.01 clearance level, Church and Duane is fine
One site is 0.03 Liberty and South End Ave.
90 structures found on TEM, also doing PCM

Standards on particulate matter are being discussed

 Panel of federal scientists coming to review data, but need to work with locals
They want to take over data analysis, data entry, which will be done
More sophisticated data analysis and presentation

Radiation
Planes did not contain depleted uranium
Flyover was cancelled due to FAA regulations
On 9-15 the DOE brought in monitoring equipment, monitoring the rubble and the
trucks that come out
No positive readings from trucks of rubble
100 samples done, ATM at Broadway and Fulton had positive reading but not high
enough to worry

Water
Sampling on Friday 9/14, bacteria were negative
PCBs and asbestos in water tanks monitored south/east of zone, DEP lab, results 9/19
No info on water tanks right now, but apparently they have started
Coord with DEP and DEC

Food and Restaurant Inspection

Sanitarians in field to monitor food distribution sites and inspect food being given out
Working with ARC
Get names of restaurants in World Financial Center, one rest, emptied out yesterday
Survey of restaurants east of Broadway that are opening.
Sanitarians walking up and down the street to do survey E of Broadway
Regular inspections will occur soon
Fulton Fish market was addressed, 28 operators showed up
Will be examining Hunts Point market tonight
State Health dept sanitarians (12 persons) can help us, starting tomorrow night
Donation of food thermometers by private group

Rodent control
Deployed 5 teams to area below Canal, 1 in WTC area
Concern about food lying around site, poses rodent risk
Will we be allowed as of yet to apply rodenticide to site

Re-occupation of buildings
Nothing

Sanitation
Plan to remove garbage below Canal St.

II. Med/Clinical Workgroup

Taking over inventory tasks of what is available at sites, for worker safety
Cloth glove ban
Re-occupancy fact sheet went out as press release
Decomposing human remains fact sheet went out yesterday to site
 III. Epi/Surveillance Workgroup
Daily summary will be available by 6 pm (see attachment)
Need for named data by fire/police agencies
A. Hospital needs assessment (A Karpati)
New form was faxed out Sat night by order of Novello
Karpati to go to GNYHA to coordinate, will stop survey as of 9/18
Need to get better data comprehensive basis, meeting today to coordinate
B. ER Acute injury/trauma surveillance (S Wilt)
1200 entered, prelim data available, see addendum
May finish with data collection today, but add a burn center
Retrospective, first 24 hours
C. Syndromic Surveillance (D Weiss)
6,000 entries from 15 hospitals, 68% other, most other injuries
2 in depth investigations from 3 clusters
EISOs getting tired, want to do 8 hour shifts, very labor intensive
2 problem hospitals, Montefiore and Columbia, but resolved
Oracle has site that hospitals can access their data, we can have overall data
14 more EISOs are coming tomorrow, investigating LIT cases among children
D. Disaster site worker surveillance for injuries and illness (A Goodman)
Added on Bellevue, Beekman, but Beth Israel and St Vincent's
Evolving, adding more questions after initial questions were taken off
Military has come in, will use the DMAT sites
Make WTC disaster conditions a reportable disease? Not possible.
•E. 911 Surveillance
No issues

MD alert #3 to go out
CDC offering IT, MIS

Regular, ongoing surveillance activities

No issues

IV. Sheltering Workgroup

10 sites in operation, potentially reduce to 5 sites
Staff assigned through tomorrow morning
Classes not schedule until tomorrow in site where there are schools
Security is an issue at one site, stolen property
Homeless people need to get their needs addressed as well
Tour by school nurses
Inventory of supplies

VI. Laboratory Workgroup

No issues
VII. Operations/Facilities
125 Worth St.: Vital records occupied, but not operating to general public, are
receiving birth certificate applications from hospitals, 28 phone lines, print shop and
mail room open, integrity tests today, do not turn on ACs
40 Worth St (private): no access yet
93 Worth St (private): is open
2 Lafayette: rumor that some power is on, full data services
225 Broadway: on evacuation/construction route, will be difficult
253 Broadway (city): on construction route, will be difficult
346 Broadway: open as of today
66 Williams St: may not be able to occupy soon

VIII. MIS

OTHER ISSUES
VIH. Public Relations

IX. Personnel/Staffing
Payroll went out last Friday very smoothly (?more smoothly than usual?!)
Fill out time cards for a regular week
Staff going to usual worksites, reporting to work
Nextel phones for managerial staff (over 300 distributed)

Prepared by THH
 Current Issues
9/17/01 Noon
DRAFT

TOPIC OUTSTANDING CONCERNS RESPONSIBLE

PARTY
Radiation and 1) Department of Energy flyovers (still not happened) to measure Gene Mishkin
Monitoring radiation levels
2) National Guard has radiation monitors on the trucks taking
garbage to Freshkill- NEED TO GET RESULTS
Pest Control 1) DOH beginning to develop area map for a zone strategy James Gibson
2) on going rodent issues? Allan Goldberg
Food 1) Fulton Fish Market clean up begun and ongoing Elliott Marcus
2) Status of periodic wash down of triage area
3) Restaurant opening and inspection status
Water 1) Sampling fire hydrants and tap water south of ground zero to Jim Luke
test for quality concerns- waiting for lab results
2) North of ground zero, sampling results were fine
Air 1) Sample results as of Sunday 2 pm were ok/COH briefed, no Jessica Leighton
outstanding levels of concern Kelly McKinney
Medical and 1) Respirator fit testing tjeams on site, Army will not do. Sue Blank
Clinical Continued need for fit testing by DOH/DOH organizing
inventory and control plan/Request to NIOSH for staff.
2) Cloth glove ban for workers needs to be followed up.
3) DC AS finally ordering hand washing kits— status.
4) Reoccupation scripts status—Public Affairs
Worker Safety 1) Health and Safety Plan (DEC/Bectel) Jessica Leighton
2) Fact sheet regarding general hygienic concerns- hand washing Kelly McKinney
and bathrooms for first responders
3) Decontamination sites for dust removal

Shelters 1) Ten open and staffed. Staffing scheduled till 9am Monday. Carmen Ramos
But continued staffing after that is planned. Low utilization
except at 4 sites. See addendum.
Surveillance 1) Casualty— City wide draft report status due Monday Marci Layton
2) Hospital—EIS staff continue to be at hospitals./status Polly Thomas
MIS No acute, emergency issues/Only chronic concerns Ed Carubis
Staff and 125 Worth Street Stu Mirsky
Operations 1) Vital Records on first floor, back on Monday am. No Kelly McKinney
customer walk-in service. Burial desk remains at C. Rich Naeder
Harlem. COH and B. Mojica back to 3rd Floor
2) Other buildings/inspections on going
3) DOH mailroom to open Wednesday
DOH 1) Telephone problems/delayed opening Mark Foggin
Complaints
Line
Bureau Liaisons for Health Centers Managers
September 17, 2001

If you need to contact a NYCDOH Bureau representative with questions and or

instructions regarding staff who present at your borough-based health centers, please
contact the person listed below at (212) 213-1694 or (212) 213-1666.

Family and Community Health: Scottie Owings-Leaks

Disease Intervention: Deborah Mack
Medical and Professional Education and Training: Roberta Gonzalez/Janice Smith
Regulatory and Environmental Health: Diana Lament
Health Care Access: Jim Capoziello/Joyce Weinsteiri
Health Support Services: Georgia Davidson
Community HealthWorks: Not Applicable
Public Affairs: Not Applicable
Legal Affairs: Not Applicable

Please note: It is essential that all staff sign-in and you collect contact information for each
person.
Environmental and Clincal Group- 9/17/01 11:44 AM

Personal Protective Equipment

I.. Respiratory

1. Elucidate what is the necessary respiratory gear.

2. Which equipment are needed and for which job lines?
In debris-Pi00/0VAG
Staging area-Pi00 or N100
Morgue-OVAG
3. How many of each are needed?
How many have been ordered?
What the current status of each order?
(Shipping ; Warehouse, Distrib'n sites)
4. Distribution of gear to workers
Where it's happening:
Amex
DMAT
Church/rector
DOT - 225 Bway
Pier 11
Jacobi Medical Station
5. Medical Screening/Fit Testing
What type of screening - what's the content? Who's disallowed
Staffing for fit testing
Training
of fit testers
of workers How to wear, how to clean, keep facepiece - only replace cartridge
How to know if malfunctioning
6. Is equipment actually being used?
7. Monitoring respiratoy injury
8. Signage - health and safety checklist; indicating where fit testing is happening
9. Resources/ team support
 Shelter Client Usage

Shelter 9/11-12 9/12 9/12-13 9/13 9/13-14 9/14 9/14-15 9/15 9/15-16 9/1.6, 9/16
9P-9A 9A-9P 9P-9A 9A-9P 9P-9A 9A-9P 9P-9A 9A-9P 9P-9A ;:~1A^ I^M-'lP
# clients # clients # clients # clients # clients # clients # clients # clients # clients #|&s
Seward Park
HS
Washington
3

2
11

75
6

20
9

36
3

38
3

17
0

2
5

27
?/
tza
f;ff £>
I

Irving HS
Fashion 5 4 20 31 21 43 9 43
Industry HS (+8 $ 6
tourists) V /jff^
Chelsea HS 3 9 1 1 0 (used for
emergency
6 2 13 • *?
1
7
6f
workers
respite)
Norman 7 20 23 5 24 4-9
/>?
Thomas HS t/ A
4 ^>

t^i
City School HS 3-5 6 7 6 8 2 (used for 3 1 3
construction
crew
respite) ^
JHS22 0 2 4 3 3 0 2
/. ¥
IS 131 10 8 6 10 10 16 8 12
# &
Comprehensive
Day&Night HS
0 0 0 0 4 1 5
[s> i
2>
Bayard Rustin
HS
6 Closed Closed Closed Closed Closed Closed
L-'f
/
^/<?
w Clc^SeA

Curtis HS, SI ~HOO 2 0 0 Closed Closed Closed Closed %%

kids /?
C-t^'^-d
Westinghouse 2 0 0 0 132
HS,BK 118
workers
workers
w^r
^ Vd^^K
Sl'Y 60i>'"'":''x^>
 Shelter Client Usage

Shelter 9/17 9/17 9/17 9/17 9/18 9/18 9/18 9/19 9/19 9/19 9/20 9/20 9/20 9/21
~1A 8A 3P IIP 8A 3P IIP 8A 3P IIP 8A 3P IIP 8A
# # # # # # # # # # # clients # clients # # clients
clients clients clients clients clients clients clients clients clients clients clients
Seward Park 5 2
O
HS
Washington 28 30 ii*
Irving HS
Fashion 44 39
Industry HS 6f
Chelsea HS 6 14
3
Norma Thomas 19 22
HS c&L-
City School HS 4 6
Z
JHS22 2 3
€>
IS 131 12 14

Comprehensive
Day&NightHS
7 6
s
Bayard Rustin Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed
HS

Curtis HS, SI Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed

Westinghouse 49 0
HS.BK worker
Jlark Fpggin - In Search of Respirators ___._-: ^___ Page 1

From: Mark Foggin <mnf203@nyu.edu>

To: <jmiller@health.nyc.gov>, <kkaye@health.nyc.gov>, <rbergman@health.nyc.gov>,
<kmckinne@health.nyc.gov>, <mfoggin@health,nyc.gov>
Date: 9/17/01 6:1 SAM
Subject: In Search of Respirators

With the patient diligence of D/C David Greenberg of DCAS and Tim K of OEM,
we spent the evening trying to determine where respirators are, where they
come from, what has arrived, and what is still needed. I visited 3
distribution sites downtown and together we visited 2 citywide warehouses
in and around the Javitz center. We have a beginning so far.

At the sites...
There are 3 or so DOH-sponsored or supported fit-testing sites and caches
of respirators at Ground Zero. This is another 1 or so DOT-specific site
for its own employees. Each has a varying level of stock of different
respirators and additional cartridges.

Supplying the site...

Comes from several different sources:
* Purchased, inventoried, stored and supplied by DCAS (storehouse to 1
Centre St)
* Supplied by FEMA
* Supplied by CDC
* Supplied by EPA
* Cached at Javitz Center (from Federal agencies and volunteers)

Details...
EPA's shipment has arrived at Edison, NJ, and is awaiting instructions on
how to be delivered. CDC and FEMA both indicate that they have provided
some materiel, that it has been "transfered to the City" and that's all
they know. DCAS indicates that they are close to the ends of their resp
supplies and will be ordering more.

(Issues...
'There is an overall lack of coordination between requests made for resps in
the field, understanding what's available in NYC, requests made for federal
assets, and understanding which of those fed requests have been fulfilled.
The Javitz Center is also problematic in that it is viewed as a robust
cache of equipment by OEM. An entensive site visit this evennig yielded no
significant stores of resiprators.

Next steps...
* Address OEM at a high level to ask it to get a better handle on its
Javitz and related store sites.
* Encourage closer work with DCAS and DOH through OEM's logistics group to
catalog exisiting stores and vet requests in the field.
* Consider asking FEMA to reach out the SW Area Wildfire unit who had the
best run and maintained cache of respiratory equipment (earmarked for their
search & rescue teams) but who is routinely called in by FEMA to do just
this sort of procurement, and provisioning. We would have to request their
help through OEM and FEMA.
* Inventory existing distribution points and create a staffing system there
that provides early warning of low supplies.

The attached chart briefly outlines the few numbers we discovered at the
 Available at DCAS now
per box boxes total
1/2 masks p100 3M 24 21 504
North 12 4 48
Wilson 10 53 530
OV North 10 12 120
Full Mask MSA 500

Cartridges pairs p100 3M 50 22 1.100

MSA 6 332 1,992
North 72 56 4,032
North 36 25 900
OV North 35 57 2,052
MSA 6 33 198
Wilson 36 51 1,836

Glove pairs Leather Palm 21.000

Welder's 144
Waterproof /Other 1,600

Goggles 140 7 980

Boots (waterproof) 372
Tyvek coveralls 12,500
iyewash 10.062
Hardhats 20 201 4,020

Delivered forward from CDC (Sept 13)

Masks N100 5.960

Goggles 3,548

Available at EPA Edison (to be transported forward?)

Masks p100 6,000

Cartridges (unclear type) 7,000
Goggles 13,000
Oust Masks 8,000

Available at Yale Building to USAR Teams (not directly to general rescue workers)

Tyvek Coveralls XL & XXL 25,200

Masks p100 3M 8293s 2,000

n95 8212s 1,250

Full Face MSA #1000 108

Goggles 3,500

Respirators Combo AO Safety 95050 650

Wipes ??
 DEPARTMENT OF HEALTH

NEAL L. COHEN, M.D. SANDRA MULLIN

Commissioner Associate Commissioner

FOR IMMEDIATE RELEASE CONTACT: SANDRA MULLIN/ANDREW TUCKER

Monday, September 17,2001 (212) 447-8232*
(917) 578-6208

HEALTH DEPARTMENT OFFERS RECOMMENDATIONS FOR INDIVIDUALS

RE-OCCUPYING COMMERCIAL BUILDINGS AND RESIDENTS
RE-ENTERING THEIR HOMES

The New York City Department of Health announced today recommendations for building
owners/managers and individuals who are being allowed to re-enter their businesses or homes for the
first time since the World Trade Center disaster on September 11. The Health Department has been
collaborating with numerous City, State, and Federal agencies to monitor potential public health
impacts in the general vicinity of the World Trade Center blast zone.

New York City Health Commissioner Neal L. Cohen, M.D., said "As some buildings near the World
Trade Center may have sustained structural damage, experienced power loss, and/or been subject to
migrating dust and debris from the blast, the Health Department working with numerous agencies
have been actively monitoring the condition of buildings in and around the blast area to determine
when occupants may safely resume tenancy. Property owners and managers are being instructed to
assess the stability and safety of their buildings. This includes checking and, if necessary, restoring
utility services."

Recommendations for Re-entry into Your Homes

In your home, first make sure that conditions are safe. Enter your home dressed in a long-sleeve shirt
and pants, and with closed shoes. Upon entry:

• Check for the smell of gas. If the apartment smells of gas, leave immediately and report it to your
building manager and to Con Edison.
• Check for broken glass and fixtures. Wrap any broken glass in paper and mark it "broken glass."
If large pieces of glass are broken, ask your building superintendent for help.
• Run hot and cold water from each of the taps for at least two minutes, or until water runs
completely clean, whichever is longer.
• Flush toilets until bowls are refilled. For air pressure systems, you may need to flush several
times. If there are any problems with the toilet or plumbing system, call a plumber — do not try
to fix the problem yourself.

- - More - -

*The Main Office of the NYC DOH has been temporarily relocated to 455 1st Avenue.
 Department of Health
World Trade Center Disaster
Emergency Operations Center
Current Issues/Agenda
9/17/01 - 1700 hours

TOPIC OUTSTANDING CONCERNS RESPONSIBLE

PARTY
Radiation and 1) Status of DOE monitoring equipment Gene Mishkin
Monitoring 2) Follow up on positive radiation at ATM
Pest Control 1) Pest control management below Canal St James Gibson
2) Garbage pickup below Canal St. Allan Goldberg
Food 1) Restaurants in World Financial Center Elliott Marcus
2) Monitoring of distribution sites
3) Fulton St. Market
4) Hunts Point Market
5) State Health Dept sanitarians
Water 1) Sampling of water for PCBs and asbestos Jim Luke
2) Agreement with state on water tank protocol
Air 1) Results of 2 pm meeting, DEC, DOH, EPA, ConEd Jessica Leighton
2) Update of air monitoring on buildings Kelly McKinney
3) Update on scientific panel to review and eval data
Medical and 1) Fit testing personnel Sue Blank
Clinical 2) Respirator availability
3) Hand washing kits
Worker Safety 1) Health and Safety Plan (DEC/Bechtel) Jessica Leighton
Kelly McKinney
Shelters 1) Security problems Carmen Ramos
2) Homeless persons
3) National ARC issues
4) Inventory of supplies
Surveillance 1) Retrospective ER injury Marci Layton
2) Hospital needs assessment/casualties Polly Thomas
3) Syndromic surveillance, Columbia, Montefiore
4) Site/worker safety surveillance
5) Medical alert
MIS l)No issues Ed Carubis
Staff and 1) Facility update Stu Mirsky
Operations Kelly McKinney
Rich Naeder
DOH 1) Telephone problems/delayed opening Mark Foggin
Complaints
Line
 3:38 PM
17 September 2001
Preliminary report: Not for distribution

WTC Retrospective Emergency Department Assessment

(This report includes data from preliminary analyses that will change as data are further
refined.)

Background:
Emergency department (ED) care during the acute phase of the disaster response was
assessed retrospectively to understand the types and quantities of injuries caused by the WTC
attack, the categories of individuals affected, and the impact on healthcare facility resources
and capacities.

Based on early statistics provided by the New York City Department of Health (NYC DoH)
and the Greater New York Hospital Association, four hospitals are believed to have provided
the majority of disaster-related care in Manhattan during the first days following the attack.
This assessment focuses on these four hospitals, however additional facilities may be
assessed if deemed appropriate by NYC DoH.

Facilities assessed:
Saint Vincent's Hospital*
Bellevue Medical Center*
Beth Israel Medical Center
NYU Downtown
*level-l trauma center

Time frame:
0800, 11 September 2001 through 0800, 13 September 2001

Information sources:
ED encounter forms
Patient charts
ED registration logs
Hospital admissions logs

Data were gathered on-site at each facility on 14 and 15, September, using a standardized
data abstraction form (appendix 1).

Descriptive Information:

Number of patients: 1281

Female: 460(37%)
Median age: 39 years (range 1-95)
3:38 PM
17 September 2001
Preliminary report: Not for distribution

Diagnostic categories below include individuals with more than one diagnosis. Categories therefore overlap.
Emergency Department Diagnoses
Total Saint Bellevue Beth NYU-
Vincent's Israel Downtown
Respiratory (all) 371 106 69 83 113
Respiratory (smoke inhalation) 316 60 50 83 123
Trauma 333 104 76 72 79
Ophthalmologic 165 74 47 30 14
Cardiac 72 31 9 23 9
Gastrointestinal 53 20 9 18 6
Burn 15 7 4 2 2
Obstetric/Gynecologic 14 0 1 10 3
Infection 24 10 7 6 1
Psychosocial 90 33 11 37 9
Unspecified

Trauma Sub-types
Laceration 120
Contusion 94
Sprain/Strain 100
Fracture 28
Crush 6

Outcomes of ED visits
Total Saint Vincent's Bellevue Beth Israel NYU-Downtown
Admitted to
143 36 39 37 30
Hospital
Discharged
963 299 177 245 241
Home
Died in
2. 1 1 0 0
ED
Unknown
87 3 3 12 69
3:38 PM
17 September 2001
Preliminary report: Not for distribution

Appendix 1 wtc4_48 data abstraction form (time range = 0800 9/11 to 0800 9/13)

Case #: Abstractor initials

Facility: Bellevue St. Vincent's NYU Beth Israel Other

Date of visit: 9/11 9/12 9/13

Time of visit:

Medrec#:

Name:

Sex: M F

Birthdate:

Zip:

WTC: Y N

Occupational category: NYPD NYFD PA Other

Injury address:

Transport: Ambulance Walk-in Unknown Other

Complaint category: Resp GI Inf Cardiac ObGyn Neurol Psych

(circle one)
Trauma (Open) Trauma (Closed) Burn

Injury Category:
(circle all that apply)
Fracture HN TS UE LE Mult Unsp

Sprain/Strain HN TS UE LE Mult Unsp

Laceration HN TS UE LE Mult Unsp

Contusion HN TS UE LE Mult Unsp

Crush HN TS UE LE Mult Unsp

Burn HN TS UE LE Mult Unsp

Concussion (closed head injury)

Eye injury

Smoke inhalation

Primary Diagnosis:
Disposition: Admitted Discharged home Died
 THE CITY OF NEW YORK
DEPARTMENT OF HEALTH
Rudolph W. Giuliani Neal L. Cohen, M.D.
Mayor Commissioner

September 17,2001

UPDATE #3: Terrorist Attack at the World Trade Center in New York
City: Medical and Public Health Issues of Urgent Concern

Please Share this Alert with the Following Key Staff at Your Hospital:
1 — Hospital Administration
2 - AH Medical and Nursing Staff
3 — Emergency Departments
4 - Hospital Safety Director
5 - Hospital Pharmacy and Laboratories

TO: Emergency Medicine Directors, Infection Control Practitioners and Infectious Disease
Physicians, and Other Persons on the NYCDOH Broadcast Facsimile Alert

~<IOM: Joel Ackelsberg, MD, MPH, Medical Director JA

Emergency Readiness and Response Unit, Communicable Disease Program
New York City Department of Health

Marcelle Layton, MD, Assistant Commissioner ML

Communicable Disease Program
New York City Department of Health

We are sending this broadcast alert to update you on urgent public health issues following the
terrorist attack at the World Trade Center on Tuesday, September 11, 2001. The New York
City Department of Health (NYCDOH) is working closely with other City, State and Federal
agencies, including the Centers for Disease Control and Prevention in a coordinated response to the
World Trade Center disaster.

I. Concerns about Public Health Issues Related to the Disaster Site

A) There is no threat to the health of the general public from decomposing human
remains at the disaster site: There are no risks of infectious disease epidemics related
to the disaster site. Bad odors that are likely to arise from decomposing bodies, although
unpleasant, are not harmful. The NYCDOH is working closely with other local, state and
federal agencies to ensure that workers on-site adhere to strict standard precautions to
avoid contact with blood or body fluids.
 During rescue operations, some rescue workers may come in contact with potentially
contaminated body fluids. If such exposures occur percutaneously, to non-intact skin, or
to mucous membranes, we suggest that facilities refer to their institutional protocols for
managing potential exposures to blood-borne pathogens, or that they consult the
infectious disease experts who routinely manage these situations in their hospitals.

B) Acute Stress Disorders: Given the traumatic experience of last week's plane crashes
into the World Trade Center, all New Yorkers, especially those personally affected by the
disaster, those providing care to the victims or their families, and those working on the
relief effort are likely to experience emotional distress. The following American Red
Cross and Department of Mental Health Hotlines can provide direct access to services:

American Red Cross (212) 787-1 dOO

English Life NET (800) 543-3638
Spanish Life NET (877) 298-3373
Chinese Life NET (877) 990-8585

C) Environmental Risks Posed by Asbestos and Dust

Asbestos was used in the construction of the World Trade Center. Tests performed by
various city, state and federal agencies indicate that asbestos may be present in low levels
in the vicinity of the World Trade Center. For workers at the site, the health risk posed
by a single exposure of short duration is very low. The risk to persons who have not been
present in the affected area following the disaster is also thought to be extremely low.
There are no tests that can be done, including chest radiographs, to tell if exposure has
occurred, nor to predict if pulmonary disease will occur in the future.

At a minimum, anyone who needs to enter the affected area should wear a disposable
cup-type (i.e., not fan-folded or duck-bill) N100 or P100 respirator and goggles. Workers
in contact with debris or surface dust in the affected area should contact their employers
or the NYCDOH (212-684-1710 or 212-684-1896) for specific recommendations
regarding needed protective equipment.

Increased particulate matter and dust released during the days since the attack may cause
eye and/or respiratory irritation, particularly for persons with underlying pulmonary
disease, including asthma or COPD. Individuals who have a history of heart and lung
conditions and who are in areas where smoke or dust is visible are advised to remain
indoors with the windows shut. It is advised that air conditioners be operated on the
"recirculate" mode, so that outside air is not pumped inside, or if this is not possible, that
they be turned off. Persons who experience difficulty breathing or chest pain are advised
to seek medical care immediately.

Environmental testing is continuing to better characterize levels of asbestos, dust

particulates and other potentially hazardous materials within the affected site and in other
off-site locations. In addition, the NYCDOH is also monitoring issues related to food and
water safety, rodent control, radiation levels and worker safety in the area around the
World Trade Center site.
 II. Surveillance for Infectious Disease Outbreaks Resulting From Bioterrorism
Since the terrorist attack on Tuesday, September 11, 2001, the NYC DOH has continued to
monitor for the possibility of a bioterrorist event in NYC. We have found NO evidence that
biological agents have been released in NYC; laboratory tests on environmental samples
taken from the affected area after the attack were all negative. Moreover, biologic agents
would likely not have survived an explosion the magnitude of the World Trade Center attack.
Accordingly, we are not recommending antibiotic prophylaxis for NYC residents.

However, we recognize the need to remain alert to the occurrence of unusual disease clusters or
manifestations, given the increased concerns raised in general about terrorism. Surveillance
systems are currently in place and include:

A) Active Emergency Department (ED) Syndromic Surveillance

In 15 hospital EDs, NYCDOH has established surveillance for illness syndromes that '
would likely occur if a biological pathogen were released covertly in NYC. Thirty
Epidemic Intelligence Service (EIS) Officers from the Centers for Disease Control and
Prevention are on-site 24 hours per day, working closely with ED staff at these facilities
to collect clinical data on all individuals presenting for evaluation. Data are analyzed
daily at the NYC DOH for trends and patterns that would signal an increase in illness
consistent with a possible BT event. In the event that this surveillance system identifies a
worrisome illness pattern, NYC DOH will initiate a rapid epidemiologic field
investigation to determine the etiology of the illness.

In addition, this syndromic surveillance system will also monitor for health effects
associated with the aftermath of the World Trade Center attack, such as increases in
respiratory illness, gastrointestinal illness, trauma and psychological distress.

B) Passive ED Syndromic Surveillance

The NYC DOH depends on local clinicians and laboratorians to identify and report
communicable diseases in a timely fashion, so that needed public health interventions can
be implemented as quickly as possible. An Appendix is included at the end of this alert
that underscores how all clinicians in NYC play a critical role in detecting and reporting
unusual disease outbreaks, such as could occur following the covert release of a
biological agent.

Ill) Reporting Fatal Cases and Information on Mortuary Issues, Including Death
Certificate Registration for Deaths Related to this Incident

a. ALL deaths directly or secondarily related to this terrorist incident should be reported
to the Office of the Chief Medical Examiner at 212-447-2030.
 b. The NYCDOH Burial Desk for registration of death certificates has been temporarily
moved to the Central Harlem Health Center.

NYC Health Department Burial Desk

Central Harlem Health Center
2238 Fifth Avenue (at 135th Street)
New York, NY 1003 5

Telephone: 212-926-2150 or 212-368-6538

FAX: 212-926-2526

IV) West Nile Viral Testing

Laboratory testing for West Nile virus is still available at the Public Health Laboratories.
However, we are unable to offer transportation pick-up service at this time due to other pressing
transportation needs. We request that hospitals arrange their own transportation of clinical
specimens (Monday-Thursday, during regular business hours) to:

Immunology Laboratory
Public Health Laboratories
455 First Avenue (between 26 and 28th St)
New York, NY 10016

TEL: 212-447-2660

Please instruct drivers to drop off the specimen(s) at the security desk in the first floor lobby.
Serum specimens should be kept refrigerated; cerebrospinal fluid specimens should be
kept frozen at ~70 °C. The West Nile virus Physician Initial Case and Laboratory Submission
Report for Viral Encephalitis/Meningitis (6/11/2001) form should be completed and a copy
included with each clinical sample. A copy of the case report form should also be faxed to 212-
532-5241. Please call the laboratory at the number listed above if you have any questions
regarding proper specimen transport.

V) Td Vaccine Availability
Standard recommendations for use of Td vaccine should be followed for wound management. If
additional vaccine supplies are needed by your hospital, please contact the NYCDOH at 212-
447-2676 or 212-213-1694.
VI) The New York City Department of Health (NYCDQH) has temporarily relocated its
headquarters to the Department's Public Health Laboratories at 455 First Avenue. As our
telephone and facsimile lines are still not working in our downtown Manhattan offices, we have
relocated to the Public Health Laboratories. Until further notice, please report only urgent
communicable and environmental health issues to the following telephone numbers:

Communicable Disease Issues: 212-447-2676 or 212-578-0823

FAX: 212-532-5241 or 212-447-2678

Environmental Issues: 212-684-1710 or 212-684-1896

For other Urgent Public Health Issues, or if above numbers do not answer:

Poison Control Center 212-POISONS or 212-764-7667

NYCDOH Command Center 212-213-1694 or 212-213-1666

FAX: 212-447-8239

Routine communicable disease reports (i.e., paper reports) should be sent by mail, as they will be
forwarded to us.

Public information sheets on the medical and public health issues related to the World Trade
Center disaster are available on the NYCDOH Website at www.nyc.gov/health.

We appreciate your cooperation and understanding as we all work together to deal with
the ongoing consequences of this tremendous tragedy.
 Attachment: Clinical Recognition and Management
of Suspected Bioterrorism Events

Healthcare providers in New York City should be alert to the illness patterns and
diagnostic clues that might signal an unusual infectious disease outbreak due to the
intentional release of a biological agent.

Look for the following clinical and epidemiological clues that are suggestive of a possible
bioterrorist event:

. Suspected or confirmed communicable diseases that are not endemic in NYC (e.g.,
anthrax, plague, tularemia, smallpox, or viral hemorrhagic fever)
• Any unusual age distributions or clustering for a rare or common disease
« Any sudden increase of illness in previously healthy individuals
« Any sudden increase in the following non-specific syndromes:
• Respiratory illness with fever
• Gastrointestinal illness
• Encephalitis or meningitis
• Neuromuscular illness (e.g., botulism)
• Fever with rash
• Bleeding disorders
Simultaneous disease outbreaks in human and animal populations
. Any unusual temporal and/or geographic clustering of illness (e.g., persons who
attended the same public event or religious gathering)

Some infections caused by biological agents present with distinctive signs that can provide
valuable diagnostic clues. In previously healthy persons presenting with a febrile illness, the
following signs and symptoms are highly suggestive of infection with certain biological agents:

Diagnostic sign Disease

• Widened mediastinum: Inhalational anthrax

• Gram negative pneumonia with hemoptysis: Pneumonic plague

• Vesicular/pustular rash starting on face and hands,

with all lesions at the same stage of development: Smallpox

Most of the potential pathogens that could be used as a biologic weapon (e.g., anthrax,
plague, and smallpox) would present initially as a non-specific influenza-like illness.
Therefore, an unusual pattern of influenza-like illness, such as increased influenza illness
occurring out of season or large numbers of previously healthy patients presenting
simultaneously, should prompt clinicians to alert the NYCDOH. These disease patterns
might represent an early start to the influenza season, the introduction of a new pandemic
strain, or could be the initial warning of a bioterrorist event.
Response to Suspected BT Event
When a NYC healthcare provider identifies any unusual cluster or manifestions of illness, please
notify the New York City Department of Health:

During Business Hours: Until we move back to our office in Downtown Manhattan,
please call NYC DOH's Communicable Disease Program at (212) 477-2676. We will
send a brief alert when our telephone number changes back again.

During Nights and Weekends: Please call the Poison Control Center at 212-764-7667.

After learning of a possible bioterrorist event, the NYC DOH will initiate an immediate
investigation to determine the cause of illness as well as the mode of transmission.

For more detailed clinical information on specific pathogens that might be used in a bioterrorist
event, consult the CDC Bioterrorism Preparedness Website: http://www.bt.cdc.gov.
 NEW YORK CITY DEPARTMENT OF HEALTH
EMPLOYEE REPORTING LOCATIONS

(Employees should report to designated contact person; in the absence of a designated

person, employees should report to building security desk. All reporting employees
should sign attendance sheet)

REPORTING LOCATIONS

BROOKLYN

BEDFORD HEALTH CENTER

485 Throop Avenue
Brooklyn, New York 11221
Contact: Vivian Toan

WILLIAMSBURG HEALTH CENTER

151 Maujer Street
Brooklyn, New York 11206
Contact: Teri Galvin

BROWNSVILLE HEALTH CENTER

259 Bristol Street
Brooklyn, New York 11212
Contact: Ricardo Baker

HOMECREST HEALTH CENTER

1601 Avenue S
Brooklyn, New York 11229
Contact: Wendy Negron & Karen Cameron

FORT GREENE HEALTH CENTER

295 Flatbush Avenue Extension
Brooklyn, New York 11201
Contact: Sheila Benjamin

CROWN HEIGHTS HEALTH CENTER

1218 Prospect Place
Brooklyn, New York 11213
Contact: Danita Armbrister & Irma Mojica

BUSHWICK HEALTH CENTER

335 Central Avenue
Brooklyn, New York 11221
Contact: Security Desk
MANHATTAN

RIVERSIDE HEALTH CENTER

160 West 100th Street
New York, New York 10025
Contact: Ellen Druckman

UPPER MANHATTAN (WASHINGTON HEIGHTS) HEALTH CENTER

600 West 168th Street
New York, New York 10032
Contact: Jeffrey Herrera

CENTRAL HARLEM HEALTH CENTER

2238 Fifth Avenue
New York, New York 10035
Contact: John Rail

LOWER MANHATTAN (CHELSEA) HEALTH CENTER

303 Ninth Avenue
New York, New York 10001
Contact: Security Desk

EAST HARLEM HEALTH CENTER

158 East 115th Street
New York, New York 10029
Contact: Security Desk

MANHATTANVILLE HEALTH CENTER

21 Old Broadway
New York, New York 10027
Contact: Security Desk

BRONX

MORRISANIA HEALTH CENTER

1309 Fulton Avenue
Bronx, New York 10458
Contact: Cathleen Santiago
TREEMONT HEALTH CENTER
1826 Arthur Avenue
Bronx, New York 10457

BERGEN BUILDING HEALTH CENTER

1932 Arthur Avenue
Bronx, New York 10457
Contact: Security Desk
QUEENS

ASTORIA HEALTH CENTER

12-26 31st A venue
Astoria, New York 11106
Contact: Rick Simeone

KEW GARDENS (QUEENS BOULEVARD) HEALTH CENTER

120-34 Queens Boulevard
Kew Gardens, New York 11424
Contact: Kim Keller

JAMAICA HEALTH CENTER

90-37 Parson Boulevard, Room 1
Jamaica, New York 11432
Contact: Marilyn Kelly

CORONA HEALTH CENTER

34-33 Junction Boulevard
Jackson Heights, New York 11372
Contact: Security Desk

STATEN ISLAND

RICHMOND HEALTH CENTER

51 Stuyvesant Place
Staten Island, New York 10301
Contact: Security Desk
 ' 3m m;il<r
Environmental and Clincal Group- 9/17/01 15:00 PM

Issues and Recommendations for Personal Protective Equipment

I. Respiratory i j
1. Issue: What respirotry protection is needed?
Recommendation: Based on consultation with National Institute of Occupational Safety and ^_i j/
Health (NIOSH) ^
At debris piles (anyone digging or metal-cutting) -P100 respirators with Organic Volatile
Acid Filter (to minimize odors of decomposing bodies). &t*\
Morgue - same. P 100 respirators with Organic Volatile Acid Filter (to minimize'odors of
decomposing bodies).
2. Issue: # of respiratory protective gear needed.
Recommendation: There are 2000-3000 persons working at the site; ~ 1500 persons/shift. It will
be important to know the turnover of work site staff. (I.e. is it the same people each shift, or do
source agencies rotate who goes in on what shift ..... meaning more gear necessary)
3. Issue: Current inventory status.
Recommendation: There should be a single agency vetting the ordering of equipment. There ci> $\$jJ<~~ C~
needs to be a single inventory tracking system (What's ordered, which warehouse things are going
to, what is the status of the orders, to which distribution sites?). It may actually be more efficient
to restart all afresh, and cut our losses.
4. Issue: Distribution of gear to workers
Recommendation: Respiratory gear should be distributed by staff dedicated to this endeavor. We
know of three sites where distribution is occurring - AMEX (Vesey and West), P.S. 89 _,
(Chambers and West), Site #3 (? Next to AMEX). DOH will dispatch 1 fit-testing team to eacli
site. Each fit-testing team will be composed of at least 1 MD, 1 RN, 3 PFIAs and a clerical person.
Right now, we are simply scheduling staff. T}vvr\
Mount Sinai has offered assistance with staffing from their Occupational Health Clinic.
The Commissioner will need to make a decision about whether we'll accept this offer.
Issue: What is currently happening at fit-testings?
Recommendation: Draft a protocol for use on-site. Protocol should include
a brief medical screening interview,
instructions on how to do a fit-test,
copies of the "Health and Safety Precautions for Resuce Workers" (currently being
updated to now include How to wear, how to clean, keep facepiece - only replace
cartridge, How to know if malfunctioning.

5. Issue: Assurance of worker protection

Recommendation: Establish surveillance system to monitor use of protective gear at each entry
site to the rubble.

6. Issue: Monitoring respiratory injury and illness among workers

Recommendation: Implement the recently-designed.

7. Issue: Signage
 Status of DQH Building Re-occupancy

• As of Tuesday, September 18th, the following DOH facilities are open for staff to
report to:
> 125 Worth St.
> 346 Broadway
> 2 Lafayette St.
> 66 John St.
• DOH staff that normally work in these Manhattan buildings should report to their
normal work location as of Tuesday, September 18th.
• All DOH facilities NORTH of Canal Street in Manhattan continue to be open for
business as usual.
• All DOH facilities in Queens, Bronx, Staten Island, and Brooklyn are open for
business as usual

The following DOH buildings are still NOT open.

• 253 Broadway
• 225 Broadway
• 40 Worth St.

HOWEVER, the following programs which are based at 253 and 225 Broadway and 40
Worth Street, are temporarily relocating to the following sites:

• As instructed, Health Stat staff should report to the East Tremont health center,
located at 1826 Arthur Avenue in the Bronx or the East Harlem health center,
located at 158 East 115th Street in Manhattan..

• In addition, Division of Health Care Access staff (excluding Health Stat staff-see
above) should report to 520 Madison Avenue, 30th Floor, in Manhattan.

• Unless otherwise instructed, all Field Operations/Inspections staff should report

to the Health Academy at Riverside Health Center at 160 W. 100th at Columbus
Ave. by 9AM.

• The Office of Gay and Lesbian Health will be operating from 2 Lafayette Street,
in Manhattan, 21st Floor and staff should report to this location.

• The Finance office located at 253 Broadway will be operating from 2 Lafayette
Street, 14th Floor and staff should report to this location.

• Central Complaints and the Call Center will be operating from the Public
Health Labs at 455 First Ave. at 26th Street and staff should report to this location.

• The Office of Minority Health will be operating from 2 Lafayette Street, 21st
Floor and staff should report to this location.
 • As instructed, Community Health Works Manhattan staff should report to the
East Harlem Health Center.

• Community Health Works Brooklyn staff should report to Bed-Sty Multiservice

Center.

• Community Health Works Queens staff should report to the Jamaica Annex.

• Community Health Works Bronx and Staten Island staff should call the East
Harlem Health Center.

Unless you have already been instructed otherwise, staff whose programs are not
mentioned or who are not located in 125 Worth, 346 Broadway or 2 Lafayette, should
continue to report to the nearest health center and sign in with the designated
representative (see next page).