Stephen Friedman

National Case-Control Study of Kaposi's Sarcoma and Pneumocystis carinii Pneumonia in Homosexual Men: Part 1, Epidemiologic Results

To identify risk factors for the occurrence of Kaposis sarcoma and Pneumocystis carinii pneumonia in homosexual men, we conducted a case-control study in New York City, San Francisco, Los Angeles, and Atlanta. Fifty patients (cases) (39 with Kaposis sarcoma, 8 with pneumocystis pneumonia, and 3 with both) and 120 matched homosexual male controls (from sexually transmitted disease clinics and private medical practices) participated in the study. The variable most strongly associated with illness was a larger number of male sex partners per year (median, 61 for patients; 27 and 25 for clinic and private practice controls, respectively). Compared with controls, cases were also more likely to have been exposed to feces during sex, have had syphilis and non-B hepatitis, have been treated for enteric parasites, and have used various illicit substances. Certain aspects of a lifestyle shared by a subgroup of the male homosexual population are associated with an increased risk of Kaposis sarcoma and pneumocystis pneumonia.

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.

Short-term and medium-term health effects of 9/11

The New York City terrorist attacks on Sept 11, 2001 (9/11), killed nearly 2800 people and thousands more had subsequent health problems. In this Review of health effects in the short and medium terms, strong evidence is provided for associations between experiencing or witnessing events related to 9/11 and post-traumatic stress disorder and respiratory illness, with a correlation between prolonged, intense exposure and increased overall illness and disability. Rescue and recovery workers, especially those who arrived early at the World Trade Center site or worked for longer periods, were more likely to develop respiratory illness than were other exposed groups. Risk factors for post-traumatic stress disorder included proximity to the site on 9/11, living or working in lower Manhattan, rescue or recovery work at the World Trade Center site, event-related loss of spouse, and low social support. Investigators note associations between 9/11 exposures and additional disorders, such as depression and substance use; however, for some health problems association with exposures related to 9/11 is unclear.

Impact of Financial Incentives on Documented Immunization Rates in the Inner City: Results of a Randomized Controlled Trial

OBJECTIVE This study determined the effect of 2 financial incentives---bonus and enhanced fee-for-service---on documented immunization rates during a second period of observation. METHODS Incentives were given to 57 randomly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 randomly selected children. Coverage from linked records from all sources was determined for a subsample of children within physician offices. RESULTS Up-to-date coverage rates documented in the charts increased significantly for children in the bonus group (49.7% to 55.6%; P <.05) and the enhanced fee-for-service group (50.8% to 58.2%; P <.01) compared with the control group. The number of immunizations given by these physicians did not change significantly, although the number of immunizations given by others and documented by physicians in the bonus group did increase (P <.05). Up-to-date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources. CONCLUSIONS Both financial incentives produced a significant increase in coverage levels. Increases were primarily due to better documentation not to better immunizing practices. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns. However, true immunization coverage was substantially higher than that documented in the charts.

Botulism and botulism-like illness in chronic drug abusers.

From 1982 to 1983 we received reports of a neurologic illness characterized by a symmetric descending paralysis in six drug abusers from widely separated geographic areas. Botulism was confirmed in two patients; type B botulinal toxin was found and Clostridium botulinum was isolated from a small abscess in one, and type A botulinal toxin was found in the serum of the other. The clinical illness in the remaining four patients, although not laboratory confirmed, was also compatible with botulism. None of the patients had histories suggestive of foodborne botulism, and wound botulism was suspected as the cause of illness. There are several reports of tetanus associated with parenteral drug abuse; wound botulism is another toxin-mediated clostridial infection that may occur as a complication of chronic drug abuse.

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.

Case–Control Study of Lung Function in World Trade Center Health Registry Area Residents and Workers

RATIONALE Residents and area workers who inhaled dust and fumes from the World Trade Center disaster reported lower respiratory symptoms in two World Trade Center Health Registry surveys (2003-2004 and 2006-2007), but lung function data were lacking. OBJECTIVES To examine the relationship between persistent respiratory symptoms and pulmonary function in a nested case-control study of exposed adult residents and area workers 7-8 years after September 11, 2001. METHODS Registrants reporting post September 11th onset of a lower respiratory symptom in the first survey and the same symptom in the second survey were solicited as potential cases. Registrants without lower respiratory symptoms in either Registry survey were solicited as potential control subjects. Final case-control status was determined by lower respiratory symptoms at a third interview (the study), when spirometry and impulse oscillometry were also performed. MEASUREMENTS AND MAIN RESULTS We identified 180 cases and 473 control subjects. Cases were more likely than control subjects to have abnormal spirometry (19% vs. 11%; P < 0.05), and impulse oscillometry measurements of elevated airway resistance (R5; 68% vs. 27%; P < 0.0001) and frequency dependence of resistance (R₅₋₂₀; 36% vs. 7%; P < 0.0001). When spirometry was normal, cases were more likely than control subjects to have elevated R₅ and R₅₋₂₀ (62% vs. 25% and 27% vs. 6%, respectively; both P < 0.0001). Associations between symptoms and oscillometry held when factors significant in bivariate comparisons (body mass index, spirometry, and exposures) were analyzed using logistic regression. CONCLUSIONS This study links persistent respiratory symptoms and oscillometric abnormalities in World Trade Center-exposed residents and area workers. Elevated R₅ and R₅₋₂₀ in cases despite normal spirometry suggested distal airway dysfunction as a mechanism for symptoms.

Chronic and Acute Exposures to the World Trade Center Disaster and Lower Respiratory Symptoms: Area Residents and Workers

OBJECTIVES We assessed associations between new-onset (post-September 11, 2001 [9/11]) lower respiratory symptoms reported on 2 surveys, administered 3 years apart, and acute and chronic 9/11-related exposures among New York City World Trade Center-area residents and workers enrolled in the World Trade Center Health Registry. METHODS World Trade Center-area residents and workers were categorized as case participants or control participants on the basis of lower respiratory symptoms reported in surveys administered 2 to 3 and 5 to 6 years after 9/11. We created composite exposure scales after principal components analyses of detailed exposure histories obtained during face-to-face interviews. We used multivariate logistic regression models to determine associations between lower respiratory symptoms and composite exposure scales. RESULTS Both acute and chronic exposures to the events of 9/11 were independently associated, often in a dose-dependent manner, with lower respiratory symptoms among individuals who lived and worked in the area of the World Trade Center. CONCLUSIONS Study findings argue for detailed assessments of exposure during and after events in the future from which potentially toxic materials may be released and for rapid interventions to minimize exposures and screen for potential adverse health effects.

Factors associated with poor control of 9/11-related asthma 10–11 years after the 2001 World Trade Center terrorist attacks

Abstract Objective: To identify key factors associated with poor asthma control among adults in the World Trade Center (WTC) Health Registry, a longitudinal study of rescue/recovery workers and community members who were directly exposed to the 2001 WTC terrorist attacks and their aftermath. Methods: We studied incident asthma diagnosed by a physician from 12 September 2001 through 31 December 2003 among participants aged ≥18 on 11 September 2001, as reported on an enrollment (2003–2004) or follow-up questionnaire. Based on modified National Asthma Education and Prevention Program criteria, asthma was considered controlled, poorly-controlled, or very poorly-controlled at the time of a 2011–2012 follow-up questionnaire. Probable post-traumatic stress disorder, depression, and generalized anxiety disorder were defined using validated scales. Self-reported gastroesophageal reflux symptoms (GERS) and obstructive sleep apnea (OSA) were obtained from questionnaire responses. Multinomial logistic regression was used to examine factors associated with poor or very poor asthma control. Results: Among 2445 participants, 33.7% had poorly-controlled symptoms and 34.6% had very poorly-controlled symptoms in 2011–2012. Accounting for factors including age, education, body mass index, and smoking, there was a dose–response relationship between the number of mental health conditions and poorer asthma control. Participants with three mental health conditions had five times the odds of poor control and 13 times the odds of very poor control compared to participants without mental health comorbidities. GERS and OSA were significantly associated with poor or very poor control. Conclusions: Rates of poor asthma control were very high in this group with post-9/11 diagnosed asthma. Comprehensive care of 9/11-related asthma should include management of mental and physical health comorbidities.

Integrating the New York Citywide Immunization Registry and the Childhood Blood Lead Registry

In February of 2004, the New York City Department of Health and Mental Hygiene completed the integration of its childhood immunization and blood lead test registry databases, each containing over 2 million children. A modular approach was used to build a separate integrated system, called Master Child Index, to include all children in both the immunization and lead test registries. The principal challenge of this integration was to properly align records so that a child represented in one database is matched with the same child in the other database. To accomplish this task as well as to identify internal duplicate records within each database, an artificial intelligence record linkage system was created. The preliminary results show high rates of accurate merging of records both within and between the two databases. The 4,610,585 records contained in both databases before Master Child Index implementation consolidated into 2,977,290 records in the integrated system. The matching system eliminated 523,720 duplicate records within the two databases and matched and merged 1,109,575 records between the two databases. The Department of Health and Mental Hygiene plans to further develop the Master Child Index and use it as the department-wide, record-matching system.