Laura DiGrande

Asthma and Posttraumatic Stress Symptoms 5 to 6 Years Following Exposure to the World Trade Center Terrorist Attack

CONTEXT The World Trade Center Health Registry provides a unique opportunity to examine long-term health effects of a large-scale disaster. OBJECTIVE To examine risk factors for new asthma diagnoses and event-related posttraumatic stress (PTS) symptoms among exposed adults 5 to 6 years following exposure to the September 11, 2001, World Trade Center (WTC) terrorist attack. DESIGN, SETTING, AND PARTICIPANTS Longitudinal cohort study with wave 1 (W1) enrollment of 71,437 adults in 2003-2004, including rescue/recovery worker, lower Manhattan resident, lower Manhattan office worker, and passersby eligibility groups; 46,322 adults (68%) completed the wave 2 (W2) survey in 2006-2007. MAIN OUTCOME MEASURES Self-reported diagnosed asthma following September 11; event-related current PTS symptoms indicative of probable posttraumatic stress disorder (PTSD), assessed using the PTSD Checklist (cutoff score > or = 44). RESULTS Of W2 participants with no stated asthma history, 10.2% (95% confidence interval [CI], 9.9%-10.5%) reported new asthma diagnoses postevent. Intense dust cloud exposure on September 11 was a major contributor to new asthma diagnoses for all eligibility groups: for example, 19.1% vs 9.6% in those without exposure among rescue/recovery workers (adjusted odds ratio, 1.5 [95% CI, 1.4-1.7]). Asthma risk was highest among rescue/recovery workers on the WTC pile on September 11 (20.5% [95% CI, 19.0%-22.0%]). Persistent risks included working longer at the WTC site, not evacuating homes, and experiencing a heavy layer of dust in home or office. Of participants with no PTSD history, 23.8% (95% CI, 23.4%-24.2%) reported PTS symptoms at either W1 (14.3%) or W2 (19.1%). Nearly 10% (9.6% [95% CI, 9.3%-9.8%]) had PTS symptoms at both surveys, 4.7% (95% CI, 4.5%-4.9%) had PTS symptoms at W1 only, and 9.5% (95% CI, 9.3%-9.8%) had PTS symptoms at W2 only. At W2, passersby had the highest rate of PTS symptoms (23.2% [95% CI, 21.4%-25.0%]). Event-related loss of spouse or job was associated with PTS symptoms at W2. CONCLUSION Acute and prolonged exposures were both associated with a large burden of asthma and PTS symptoms 5 to 6 years after the September 11 WTC attack.

Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: A review of the literature among highly exposed populations

The September 11, 2001 (9/11), terrorist attacks were unprecedented in their magnitude and aftermath. In the wake of the attacks, researchers reported a wide range of mental and physical health outcomes, with posttraumatic stress disorder (PTSD) the one most commonly studied. In this review, we aim to assess the evidence about PTSD among highly exposed populations in the first 10 years after the 9/11 attacks. We performed a systematic review. Eligible studies included original reports based on the full Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.; American Psychiatric Association, 2000) criteria of PTSD among highly exposed populations such as those living or working within close proximity to the World Trade Center (WTC) and the Pentagon in New York City and Washington, DC, respectively, and first responders, including rescue, cleaning, and recovery workers. The large body of research conducted after the 9/11 attacks in the past decade suggests that the burden of PTSD among persons with high exposure to 9/11 was substantial. PTSD that was 9/11-related was associated with a wide range of correlates, including sociodemographic and background factors, event exposure characteristics, loss of life of significant others, and social support factors. Few studies used longitudinal study design or clinical assessments, and no studies reported findings beyond six years post-9/11, thus hindering documentation of the long-term course of confirmed PTSD. Future directions for research are discussed.

Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2-3 years after the September 11, 2001 terrorist attacks

Manhattan residents living near the World Trade Center may have been particularly vulnerable to posttraumatic stress disorder (PTSD) after the September 11, 2001 (9/11) terrorist attacks. In 2003-2004, the authors administered the PTSD Checklist to 11,037 adults who lived south of Canal Street in New York City on 9/11. The prevalence of probable PTSD was 12.6% and associated with older age, female gender, Hispanic ethnicity, low education and income, and divorce. Injury, witnessing horror, and dust cloud exposure on 9/11 increased risk for chronic PTSD. Postdisaster risk factors included evacuation and rescue and recovery work. The results indicate that PTSD is a continued health problem in the local community. The relationship between socioeconomic status and PTSD suggests services must target marginalized populations. Followup is necessary on the course and long-term consequences of PTSD.

Gender differences in probable posttraumatic stress disorder among police responders to the 2001 World Trade Center terrorist attack

BACKGROUND Police responders to the 2001 World Trade Center (WTC) disaster were previously reported to have an increased prevalence of probable posttraumatic stress disorder (PTSD). METHODS Four thousand seventeen police responders (3,435 men and 582 women) were interviewed 2-3 years after 9/11/01 as part of the World Trade Center Health Registry. Demographic, occupational, and event-specific risk factors were evaluated for probable PTSD, determined by DSM-IV criteria using the Posttraumatic Stress Checklist (PCL). RESULTS Overall prevalence of probable PTSD was 8.3% (women: 13.9%; men: 7.4%, P < 0.001). Risk factors for both genders included 9/11-related injury and older age. For men, specific risk factors were: presence in WTC Towers on 9/11 and Hispanic ethnicity; and for women, witnessing horror and education less than a college degree. CONCLUSIONS Significantly higher prevalence of probable PTSD was found for female police responders. Although consistent with civilian populations, this finding contrasts with other studies of PTSD and WTC rescue and recovery workers, and police prior to 9/11.

Long‐term course of probable PTSD after the 9/11 attacks: A study in urban primary care

Although the short- and midterm psychological effects of the attacks on September 11, 2001 (9/11) have been well described, less is known about the long-term effects. This study examines the course of probable posttraumatic stress disorder (PTSD), its predictors and clinical consequences in a cohort of 455 primary care patients in New York City, interviewed approximately 1 and 4 years after 9/11. The rate of PTSD decreased from 9.6% to 4.1%. Pre-9/11 major depressive disorder emerged as the strongest predictor of PTSD, particularly late-PTSD. At follow-up, late-PTSD was associated with major depressive and anxiety disorders, and PTSD regardless of timing was associated with impaired functioning. Findings highlight the importance of ongoing evaluation of mental health needs in primary care settings in the aftermath of disasters.

Respiratory and other health effects reported in children exposed to the World Trade Center disaster of 11 September 2001.

Background Effects of the World Trade Center (WTC) disaster on children’s respiratory health have not been definitively established. Objective This report describes respiratory health findings among children who were < 18 years of age on 11 September 2001 (9/11) and examine associations between disaster-related exposures and respiratory health. Methods Children recruited for the WTC Health Registry (WTCHR) included child residents and students (kindergarten through 12th grade) in Manhattan south of Canal Street, children who were south of Chambers Street on 9/11, and adolescent disaster-related workers or volunteers. We collected data via computer-assisted telephone interviews in 2003–2004, with interview by adult proxy for children still < 18 years of age at that time. We compared age-specific asthma prevalence with National Health Interview Survey estimates. Results Among 3,184 children enrolled, 28% were < 5 years of age on 9/11; 34%, 5–11 years; and 39%, 12–17 years. Forty-five percent had a report of dust cloud exposure on 9/11. Half (53%) reported at least one new or worsened respiratory symptom, and 5.7% reported new asthma diagnoses. Before 9/11, age-specific asthma prevalence in enrolled children was similar to national estimates, but prevalence at interview was elevated among enrollees < 5 years of age. Dust cloud exposure was associated with new asthma diagnosis (adjusted odds ratio = 2.3; 95% confidence interval, 1.5–3.5). Conclusions Asthma prevalence after 9/11 among WTCHR enrollees < 5 years of age was higher than national estimates, and new asthma diagnosis was associated with dust cloud exposure in all age groups. We will determine severity of asthma and persistence of other respiratory symptoms on follow-up surveys.

Posttraumatic Stress after the 9/11 Attacks: An Examination of National, Local, and Special Population Studies

The terrorist attacks on the World Trade Center and the Pentagon on the morning of September 11, 2001, have shattered assumptions of safety for many people living in the United States and abroad. Whether one was in New York, Washington DC, other parts of the country, or elsewhere in the world, the images of how the disaster unfolded and the subsequent rescue, recovery, and rebuilding efforts are apt to be easily recollected from memory. The events are still a part of our everyday experience, filtered through the resulting war on terrorism and subsequent threats and attacks in other parts of the world by terrorist groups.

World Trade Center Disaster and Asthma Type: Thomas et al. Respond

We appreciate the question raised by Ziem regarding the type of asthma reported in children exposed to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) (Thomas et al. 2008). In our study we found an increase in age-specific asthma prevalence among children < 12 years of age, and a new diagnosis of asthma was strongly correlated with a report of exposure to the dust and debris cloud that occurred as buildings collapsed on 9/11. Among children < 5 years of age, we observed an increased prevalence in asthma diagnosis even among those not exposed to the dust cloud. We cannot confirm or disprove Ziem’s very reasonable suggestion that the asthma seen here was irritant rather than allergen induced. The data on asthma diagnoses were reported by parents or other guardians of the children, using a very simple standardized question. We asked whether a medical provider had ever said the child had asthma, and if yes, whether this occurred before or after 9/11. We did not collect information on severity, treatment, or duration, and did not review medical records. A follow-up survey of the children is under way and includes questions to characterize the asthma illness, but those data are not yet available. In small children, in addition to airborne irritants and atopy, respiratory viruses may also play a role in initiation or exacerbation of asthma (Schwarze and Gelfand 2000). It is difficult or impossible in a general pediatric setting to differentiate the type of asthma in children, and many pediatricians use the term “reactive airway disease” in children with recurrent wheezing whether or not there appears to be an allergic component. The airborne contaminants immediately following the 9/11 attacks included a highly alkaline mixture of gypsum, concrete, and synthetic vitreous fibers, further contaminated by metals, organochlorine compounds such as polychlorinated biphenyls and dioxins, and polycylic aromatic hydrocarbons. Later on, settled dust in indoor environments, including residences where many children lived, was found to consist of both fine, coarse, and “supercoarse” (> 10 μm in diameter) particulate matter (Lioy et al. 2006); thus, there was a clear potential for exposure to biologic or allergenic substances. Also, as the cleanup for homes, as well as public areas, was prolonged and difficult, molds could have occurred in some environments and contributed to allergic reactions. Based on earlier studies, Landrigan et al. (2004) noted that “high alkalinity of WTC dust produced bronchial hyperreactivity, persistent cough, and increased risk of asthma.” Increased asthma was subsequently reported in evaluations of 68,444 adults enrolled in the WTC Health Registry (Farfel et al. 2008). Wheeler et al. (2007) found a dose response with increased exposure to the 16-acre “pile” of debris associated with the buildings’ collapse and burning. In an overview of health effects in other adults, Farfel et al. (2008) found an association of asthma with exposure to the initial dust cloud generated by the collapse of the twin towers. We agree with Ziem that, in both children and adults, the exposures observed are more likely related to particulates and other irritants. Further work that includes more detailed histories accompanied by pulmonary function testing is needed to better characterize the pulmonary illness in these individuals.