Sara A. Miller-Archie

Heart disease among adults exposed to the September 11, 2001 World Trade Center disaster: results from the World Trade Center Health Registry.

OBJECTIVE To examine associations between 9/11-related exposures, posttraumatic stress disorder (PTSD), and subsequent development of heart disease (HD). METHODS We prospectively followed 39,324 WTC Health Registry participants aged ≥18 on 9/11 for an average of 2.9 years. HD was defined as self-reported physician-diagnosed angina, heart attack, and/or other HD reported between study enrollment (2003-2004) and a follow-up survey (2006-2008) in enrollees without previous HD. A PTSD Checklist (PCL) score ≥44 was considered PTSD. We calculated adjusted hazard ratios (AHR) and 95% confidence intervals (CI) to examine relationships between 9/11-related exposures and HD. RESULTS We identified 1162 HD cases (381 women, 781 men). In women, intense dust cloud exposure was significantly associated with HD (AHR 1.28, 95% CI 1.02-1.61). Injury on 9/11 was significantly associated with HD in women (AHR 1.46, 95% CI 1.19-1.79) and in men (AHR 1.33, 95% CI 1.15-1.53). Participants with PTSD at enrollment had an elevated HD risk (AHR 1.68, 95% CI 1.33-2.12 in women, AHR 1.62, 95% CI 1.34-1.96 in men). A dose-response relationship was observed between PCL score and HD risk. CONCLUSION This exploratory study suggests that exposure to the WTC dust cloud, injury on 9/11 and 9/11-related PTSD may be risk factors for HD.

Gastroesophageal Reflux Symptoms and Comorbid Asthma and Posttraumatic Stress Disorder Following the 9/11 Terrorist Attacks on World Trade Center in New York City

OBJECTIVES:Excess gastroesophageal reflux disease (GERD) was reported in several populations exposed to the September 11 2001 (9/11) terrorist attacks on the World Trade Center (WTC). We examined new onset gastroesophageal reflux symptoms (GERS) since 9/11 and persisting up to 5–6 years in relation to 9/11-related exposures among the WTC Health Registry enrollees, and potential associations with comorbid asthma and posttraumatic stress disorder (PTSD).METHODS:This is a retrospective analysis of 37,118 adult enrollees (i.e., rescue/recovery workers, local residents, area workers, and passersby in lower Manhattan on 9/11) who reported no pre-9/11 GERS and who participated in two Registry surveys 2–3 and 5–6 years after 9/11. Post-9/11 GERS (new onset since 9/11) reported at first survey, and persistent GERS (post-9/11 GERS reported at both surveys) were analyzed using log-binomial regression.RESULTS:Cumulative incidence was 20% for post-9/11 GERS and 13% for persistent GERS. Persistent GERS occurred more often among those with comorbid PTSD (24%), asthma (13%), or both (36%) compared with neither of the comorbid conditions (8%). Among enrollees with neither asthma nor PTSD, the adjusted risk ratio (aRR) for persistent GERS was elevated among: workers arriving at the WTC pile on 9/11 (aRR=1.6; 95% confidence interval (CI) 1.3–2.1) or working at the WTC site > 90 days (aRR=1.6; 1.4–2.0); residents exposed to the intense dust cloud on 9/11 (aRR=1.5; 1.0–2.3), or who did not evacuate their homes (aRR=1.7; 1.2–2.3); and area workers exposed to the intense dust cloud (aRR=1.5; 1.2–1.8).CONCLUSIONS:Disaster-related environmental exposures may contribute to the development of GERS. GERS may be accentuated in the presence of asthma or PTSD.

Cardiovascular Disease Hospitalizations in Relation to Exposure to the September 11, 2001 World Trade Center Disaster and Posttraumatic Stress Disorder

Background A cohort study found that 9/11‐related environmental exposures and posttraumatic stress disorder increased self‐reported cardiovascular disease risk. We attempted to replicate these findings using objectively defined cardiovascular disease hospitalizations in the same cohort. Methods and Results Data for adult World Trade Center Health Registry enrollees residing in New York State on enrollment and no cardiovascular disease history (n=46 346) were linked to a New York State hospital discharge–reporting system. Follow‐up began at Registry enrollment (2003–2004) and ended at the first cerebrovascular or heart disease (HD) hospitalization, death, or December 31, 2010, whichever was earliest. We used proportional hazards models to estimate adjusted hazard ratios (AHRs) for HD (n=1151) and cerebrovascular disease (n=284) hospitalization during 302 742 person‐years of observation (mean follow‐up, 6.5 years per person), accounting for other factors including age, race/ethnicity, smoking, and diabetes. An elevated risk of HD hospitalization was observed among women (AHR 1.32, 95% CI 1.01 to 1.71) but not men (AHR 1.16, 95% CI 0.97 to 1.40) with posttraumatic stress disorder at enrollment. A high overall level of World Trade Center rescue and recovery–related exposure was associated with an elevated HD hospitalization risk in men (AHR 1.82, 95% CI 1.06 to 3.13; P for trend=0.05), but findings in women were inconclusive (AHR 3.29, 95% CI 0.85 to 12.69; P for trend=0.09). Similar associations were observed specifically with coronary artery disease hospitalization. Posttraumatic stress disorder increased the cerebrovascular disease hospitalization risk in men but not in women. Conclusions 9/11‐related exposures and posttraumatic stress disorder appeared to increase the risk of subsequent hospitalization for HD and cerebrovascular disease. This is consistent with findings based on self‐reported outcomes.

Posttraumatic stress disorder and new-onset diabetes among adult survivors of the World Trade Center disaster.

OBJECTIVE To explore the temporal relationship between 9/11-related posttraumatic stress disorder (PTSD) and new-onset diabetes in World Trade Center (WTC) survivors up to 11 years after the attack in 2001. METHODS Three waves of surveys (conducted from 2003 to 2012) from the WTC Health Registry cohort collected data on physical and mental health status, sociodemographic characteristics, and 9/11-related exposures. Diabetes was defined as self-reported, physician-diagnosed diabetes reported after enrollment. After excluding prevalent cases, there were 36,899 eligible adult enrollees. Logistic regression and generalized multilevel growth models were used to assess the association between PTSD measured at enrollment and subsequent diabetes. RESULTS We identified 2143 cases of diabetes. After adjustment, we observed a significant association between PTSD and diabetes in the logistic model [adjusted odds ratio (AOR) 1.28, 95% confidence interval (CI) 1.14-1.44]. Results from the growth model were similar (AOR 1.37, 95% CI 1.23-1.52). CONCLUSION This exploratory study found that PTSD, a common 9/11-related health outcome, was a risk factor for self-reported diabetes. Clinicians treating survivors of both the WTC attacks and other disasters should be aware that diabetes may be a long-term consequence.

Asthma among Staten Island fresh kills landfill and barge workers following the September 11, 2001 World Trade Center terrorist attacks

BACKGROUND Although airborne respiratory irritants at the World Trade Center (WTC) site have been associated with asthma among WTC Ground Zero workers, little is known about asthma associated with work at the Staten Island landfill or barges. METHODS To evaluate the risk of asthma first diagnosed among Staten Island landfill and barge workers, we conducted a survey and multivariable logistic regression analysis regarding the association between Staten Island landfill and barge-related work exposures and the onset of post-9/11 asthma. RESULTS Asthma newly diagnosed between September 11, 2001 and December 31, 2004 was reported by 100/1,836 (5.4%) enrollees. Jobs involving sifting, digging, welding, and steel cutting, enrollees with high landfill/barge exposure index scores or who were police and sanitation workers, and enrollees with probable posttraumatic stress disorder all had increased odds ratios for new-onset asthma. CONCLUSIONS Post-9/11 asthma cumulative incidence among Staten Island landfill/barge workers was similar to that of other WTC disaster rescue and recovery workers. Am. J. Ind. Med. 59:795-804, 2016.

Hospitalizations for asthma among adults exposed to the September 11, 2001 World Trade Center terrorist attack

ABSTRACT Objective: We described the patterns of asthma hospitalization among persons exposed to the 2001 World Trade Center (WTC) attacks, and assessed whether 9/11-related exposures or comorbidities, including posttraumatic stress disorder (PTSD) and gastroesophageal reflux symptoms (GERS), were associated with an increased rate of hospitalization. Methods: Data for adult enrollees in the WTC Health Registry, a prospective cohort study, with self-reported physician-diagnosed asthma who resided in New York State on 9/11 were linked to administrative hospitalization data to identify asthma hospitalizations during September 11, 2001–December 31, 2010. Multivariable zero-inflated Poisson regression was used to examine associations among 9/11 exposures, comorbid conditions, and asthma hospitalizations. Results: Of 11 471 enrollees with asthma, 406 (3.5%) had ≥1 asthma hospitalization during the study period (721 total hospitalizations). Among enrollees diagnosed before 9/11 (n = 6319), those with PTSD or GERS had over twice the rate of hospitalization (adjusted rate ratio (ARR) = 2.5, 95% CI = 1.4–4.1; ARR = 2.1, 95% CI = 1.3–3.2, respectively) compared to those without. This association was not statistically significant in enrollees diagnosed after 9/11. Compared to higher educational attainment, completing less than college was associated with an increased hospitalization rate among participants with both pre-9/11- and post-9/11-onset asthma (ARR = 1.9, 95% CI = 1.2–2.9; ARR = 2.6, 95% CI = 1.6–4.1, respectively). Sinus symptoms, exposure to the dust cloud, and having been a WTC responder were not associated with asthma hospitalization. Conclusions: Among enrollees with pre-9/11 asthma, comorbid PTSD and GERS were associated with an increase in asthma hospitalizations. Management of these comorbidities may be an important factor in preventing hospitalization.

Post-9/11 drug- and alcohol- related hospitalizations among World Trade Center Health Registry enrollees, 2003–2010

OBJECTIVE To describe patterns of drug- and alcohol-related hospitalizations among persons exposed to the 2001 World Trade Center (WTC) terrorist attacks and to assess whether 9/11-related exposures or post-9/11 post-traumatic stress disorder (PTSD) were associated with increased odds of hospitalization. METHODS Data for adult enrollees in the WTC Health Registry, a prospective cohort study, were linked to New York State (NYS) administrative hospitalization data to identify alcohol- and drug-related hospitalizations from enrollment to December 31, 2010. Logistic regression was used to analyze the associations between substance use-related hospitalization, 9/11-related exposure and PTSD. RESULTS Of 41,176 NYS resident enrollees, we identified 626 (1.5%) who had at least one alcohol- or drug-related hospitalization; 53.4% (n = 591) of these hospitalizations were for alcohol only diagnoses and 46.6% (n = 515) were drug-related. Witnessing ≥3 traumatic events on 9/11 was significantly associated with having a drug-related hospitalization (AOR 1.4, 95% CI = [1.1, 1.9]). PTSD was significantly associated with both having a drug-related hospitalization as well as an alcohol only-related hospitalization. (AOR 2.6, 95% CI = [2.0, 3.3], AOR 1.8, 95% CI = [1.4, 2.3], respectively). CONCLUSIONS Witnessing traumatic events and having PTSD were independently associated with substance use-related hospitalizations. Targeting people who witnessed traumatic events on 9/11 and/or who have PTSD for substance use- treatment could reduce alcohol and drug-related hospitalizations connected to 9/11.

Considerations for future disaster registries: Effectiveness of treatment referral outreach in addressing long-term unmet 9/11 disaster needs

Purpose The purpose of this paper is to evaluate the effectiveness of a targeted outreach program that referred World Trade Center Health Registry (Registry) enrollees, to specific post-disaster health care available through the World Trade Center Health Program (WTCHP) and evaluate differences in outreach effectiveness based on demographic and health characteristics. Design/methodology/approach The Registry’s Treatment Referral Program (TRP) targeted 22,981 enrollees based on symptoms and conditions known to be related to 9/11, reported on a 2011-2012 follow-up survey. A call vendor was utilized for the initial outreach phone call. Enrollees who requested a WTCHP application had follow-up from TRP staff, which typically included 4-6 interactions per enrollee until outreach was completed. Findings As of 12/31/2015, the vendor had reached 8,778 (38 percent) of the targeted sample. TRP staff spoke to 6,016 (68 percent) enrollees reached by the vendor, 5,554 (92 percent) of whom requested a WTCHP application, and 2,425 (43 percent) reported having submitted the WTCHP application. Application requests and submissions differed by survivor or responder status, race, income and health symptoms. Originality/value Registries created for surveillance and research among disaster-exposed populations provide a unique and effective outreach approach. A dedicated treatment referral unit within a disaster registry is an effective means for conducting post-disaster outreach to a large, diverse sample of exposed individuals.

Relationship between Persistent Post-traumatic Stress Disorder and Human Remains Exposure for Staten Island Barge and Landfill Recovery and Clean-up Workers After 9/11

After the September 11, 2001 World Trade Center (WTC) disaster, recovery and clean-up efforts were concentrated at the WTC site and the Staten Island (SI) Fresh Kills landfill and barges. Research is limited regarding the long-term health effects of human remains exposure during clean-up and recovery work at the SI landfill and barges. We studied 1,592 WTC Health Registry enrollees who worked at the SI landfill, loading piers and barges after the 9/11/01 attacks to assess the relationship between remains exposure and persistent posttraumatic stress disorder (PTSD) 10-11 years later. A dose-response relationship was found between frequency of human remains exposure and persistent PTSD (adjusted odds ratio (AOR): every day (AOR) = 4.77; 95% confidence interval (CI): 2.00-11.52, almost every day (AOR) = 4.35; 95% CI: 1.75-10.80), and some days (AOR) = 2.98; 95% CI: 1.43-6.22). When exposed to human remains, sanitation workers had higher odds of persistent PTSD, compared to firefighters and police. In addition, respondents who scored lower on a social support scale had higher odds of persistent PTSD. The findings highlight the need for strategies to reduce the risk of PTSD associated with exposure to human remains in future disasters.