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Special Issue "Long-Term Health Effects of the 9/11 Disaster"

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Environmental Health".

Deadline for manuscript submissions: closed (28 February 2019).

Special Issue Editors

Guest Editor
Dr. Robert M Brackbill

World Trade Center Health Registry, Division of Epidemiology, Department of Health and Mental Hygiene, 125 Worth St, Floor 10, New York City, NY 10013, USA
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Interests: public health, environmental epidemiology, psychiatric epidemiology, long term health effects of disaster related trauma, disaster preparedness
Guest Editor
Dr. Judith Graber

Department of Epidemiology, Rutgers School of Public Health, Environmental and Occupational Health Sciences Institute, Piscataway, NJ 08854, USA
Website | E-Mail
Interests: occupational dust exposure; cancer
Guest Editor
Dr. W. Allen Robison

The National Institute for Occupational Safety and Health, (NIOSH), Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329-4027, USA
E-Mail
Interests: exposure assessment; toxicology; disaster preparedness; occupational safety and health; risk assessment

Special Issue Information

Dear Colleagues,

The International Journal of Environmental Research and Public Health is planning on publishing a Special Issue on the “Long-Term Health Effects of the 9/11 Disaster”. The terrorist attacks on the World Trade Center towers, on September 11, 2001, also referred as 9/11, was an iconic event in US history that altered the global and political response to terrorism. The attacks which involved two planes hitting the twin towers in Lower Manhattan in New York City resulted in the collapse of the buildings and over 2800 deaths of occupants of the buildings, fire, police and other responders and persons on the street in the vicinity of the collapsing buildings. The destroyed towers and the surrounding buildings have since been replaced but the health effects that resulted from the release of tons of dust, gases and debris as well as the life threat trauma are ongoing and represent a major health burden among persons directly exposed. Hundreds of scientific publications have documented the physical and mental health effects attributed to the disaster. The current state-of-the-art in understanding the ongoing interactions of physical and mental health, especially PTSD, and the unique mechanisms by which pollutants from the building collapse have resulted in long term pulmonary dysfunction, course of previously reported conditions, potential emerging conditions (e.g., heart disease and autoimmune diseases), as well as quality of life, functioning and unmet health care needs would be in the purview of this Special Issue on 9/11 Disaster.

Dr. Robert M. Brackbill
Dr. Judith Graber
Dr. W. Allen Robison
Guest Editor

Manuscript Submission Information

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Keywords

  • 9/11 Disaster
  • Physical and mental health
  • PTSD
  • Pulmonary dysfunction
  • Quality of life

Published Papers (23 papers)

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Research

Open AccessArticle
Air Pollution/Irritants, Asthma Control, and Health-Related Quality of Life among 9/11-Exposed Individuals with Asthma
Int. J. Environ. Res. Public Health 2019, 16(11), 1924; https://doi.org/10.3390/ijerph16111924
Received: 25 April 2019 / Revised: 23 May 2019 / Accepted: 25 May 2019 / Published: 30 May 2019
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Abstract
Asthma control is suboptimal among World Trade Center Health Registry (WTCHR) enrollees. Air pollution/irritants have been reported as the most prevalent trigger among World Trade Center responders. We examined the relationship between air pollution/irritants and asthma control. We also evaluated the association of [...] Read more.
Asthma control is suboptimal among World Trade Center Health Registry (WTCHR) enrollees. Air pollution/irritants have been reported as the most prevalent trigger among World Trade Center responders. We examined the relationship between air pollution/irritants and asthma control. We also evaluated the association of asthma control with health-related quality of life (HRQoL). We included 6202 enrollees age ≥18 with a history of asthma who completed the WTCHR asthma survey between 2015 and 2016. Based on modified National Asthma Education and Prevention Program criteria, asthma was categorized as controlled, poorly-controlled, or very poorly-controlled. HRQoL indicators include ≥14 unhealthy days, ≥14 activity limitation days, and self-rated general health. We used multinomial logistic regression for asthma control, and unconditional logistic regression for HRQoL, adjusting for covariates. Overall, 27.1% had poorly-controlled and 32.2% had very poorly-controlled asthma. Air pollution/irritants were associated with poorly-controlled (adjusted odds ratio (AOR) = 1.70; 95% CI = 1.45–1.99) and very poorly-controlled asthma (AOR = 2.15; 95% CI = 1.83–2.53). Poor asthma control in turn worsened the HRQoL of asthmatic patients. Very poorly-controlled asthma was significantly associated with ≥14 unhealthy days (AOR = 3.60; 95% CI = 3.02–4.30), ≥14 activity limitation days (AOR = 4.37; 95% CI = 3.48–5.50), and poor/fair general health status (AOR = 4.92; 95% CI = 4.11–5.89). Minimizing World Trade Center (WTC) asthmatic patients’ exposure to air pollution/irritants may improve their disease management and overall well-being. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Genetic Variants Associated with FDNY WTC-Related Sarcoidosis
Int. J. Environ. Res. Public Health 2019, 16(10), 1830; https://doi.org/10.3390/ijerph16101830
Received: 15 February 2019 / Revised: 2 May 2019 / Accepted: 19 May 2019 / Published: 23 May 2019
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Abstract
Sarcoidosis is a systemic granulomatous disease of unknown etiology. It may develop in response to an exposure or inflammatory trigger in the background of a genetically primed abnormal immune response. Thus, genetic studies are potentially important to our understanding of the pathogenesis of [...] Read more.
Sarcoidosis is a systemic granulomatous disease of unknown etiology. It may develop in response to an exposure or inflammatory trigger in the background of a genetically primed abnormal immune response. Thus, genetic studies are potentially important to our understanding of the pathogenesis of sarcoidosis. We developed a case-control study which explored the genetic variations between firefighters in the Fire Department of the City of New York (FDNY) with World Trade Center (WTC)-related sarcoidosis and those with WTC exposure, but without sarcoidosis. The loci of fifty-one candidate genes related to granuloma formation, inflammation, immune response, and/or sarcoidosis were sequenced at high density in enhancer/promoter, exonic, and 5’ untranslated regions. Seventeen allele variants of human leukocyte antigen (HLA) and non-HLA genes were found to be associated with sarcoidosis, and all were within chromosomes 1 and 6. Our results also suggest an association between extrathoracic involvement and allele variants of HLA and non-HLA genes found not only on chromosomes 1 and 6, but also on chromosomes 16 and 17. We found similarities between genetic variants with WTC-related sarcoidosis and those reported previously in sporadic sarcoidosis cases within the general population. In addition, we identified several allele variants never previously reported in association with sarcoidosis. If confirmed in larger studies with known environmental exposures, these novel findings may provide insight into the gene-environment interactions key to the development of sarcoidosis. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Post-9/11 Peripheral Neuropathy Symptoms among World Trade Center-Exposed Firefighters and Emergency Medical Service Workers
Int. J. Environ. Res. Public Health 2019, 16(10), 1727; https://doi.org/10.3390/ijerph16101727
Received: 26 April 2019 / Revised: 8 May 2019 / Accepted: 14 May 2019 / Published: 16 May 2019
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Abstract
Peripheral neuropathy can result from numerous conditions including metabolic disorders, inflammatory disease, or exposure to environmental or biological toxins. We analyzed questionnaire data from 9239 Fire Department of the City of New York (FDNY) World Trade Center (WTC)-exposed firefighters and emergency medical service [...] Read more.
Peripheral neuropathy can result from numerous conditions including metabolic disorders, inflammatory disease, or exposure to environmental or biological toxins. We analyzed questionnaire data from 9239 Fire Department of the City of New York (FDNY) World Trade Center (WTC)-exposed firefighters and emergency medical service workers (EMS) to evaluate the association between work at the WTC site and subsequent peripheral neuropathy symptoms using the validated Diabetic Neuropathy Symptom (DNS) score. We grouped the population into an “Indicated” group with conditions known to be associated with paresthesia (N = 2059) and a “Non-Indicated” group without conditions known to be associated (N = 7180). The level of WTC exposure was categorized by time of arrival to the WTC. Overall, 25% of workers aged 40 and older reported peripheral neuropathy symptoms: 30.6% in the Indicated and 23.8% in the Non-Indicated groups, respectively. Multivariable logistic models performed on the Non-Indicated group, and on the Non-Indicated in comparison with non-WTC exposed National Health and Nutrition Examination Survey (NHANES), found that the highest level of WTC-exposure was significantly associated with DNS positive outcomes, after controlling for potential confounders. In conclusion, this study suggests that symptoms of peripheral neuropathy and paresthesias are common and are associated with WTC-exposure intensity. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Abnormalities on Chest Computed Tomography and Lung Function Following an Intense Dust Exposure: A 17-Year Longitudinal Study
Int. J. Environ. Res. Public Health 2019, 16(9), 1655; https://doi.org/10.3390/ijerph16091655
Received: 15 February 2019 / Revised: 29 April 2019 / Accepted: 9 May 2019 / Published: 13 May 2019
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Abstract
Fire Department of the City of New York (FDNY) firefighters experienced intense dust exposure working at the World Trade Center (WTC) site on and after 11/9/2001 (9/11). We hypothesized that high-intensity WTC exposure caused abnormalities found on chest computed tomography (CT). Between 11/9/2001–10/9/2018, [...] Read more.
Fire Department of the City of New York (FDNY) firefighters experienced intense dust exposure working at the World Trade Center (WTC) site on and after 11/9/2001 (9/11). We hypothesized that high-intensity WTC exposure caused abnormalities found on chest computed tomography (CT). Between 11/9/2001–10/9/2018, 4277 firefighters underwent a clinically-indicated chest CT. Spirometric measurements and symptoms were recorded during routine medical examinations. High-intensity exposure, defined as initial arrival at the WTC on the morning of 9/11, increased the risk of bronchial wall thickening, emphysema, and air trapping. Early post-9/11 symptoms of wheeze and shortness of breath were associated with bronchial wall thickening, emphysema, and air trapping. The risk of accelerated forced expiratory volume at one second (FEV1) decline (>64 mL/year decline) increased with bronchial wall thickening and emphysema, but decreased with air trapping. The risk of airflow obstruction also increased with bronchial wall thickening and emphysema but decreased with air trapping. In a previously healthy occupational cohort, high-intensity WTC exposure increased the risk for CT abnormalities. Bronchial wall thickening and emphysema were associated with respiratory symptoms, accelerated FEV1 decline, and airflow obstruction. Air trapping was associated with respiratory symptoms, although lung function was preserved. Physiologic differences between CT abnormalities suggest that distinct types of airway injury may result from a common exposure. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Molecular Study of Thyroid Cancer in World Trade Center Responders
Int. J. Environ. Res. Public Health 2019, 16(9), 1600; https://doi.org/10.3390/ijerph16091600
Received: 9 April 2019 / Revised: 1 May 2019 / Accepted: 2 May 2019 / Published: 7 May 2019
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Abstract
Thyroid cancer incidence is higher in World Trade Center (WTC) responders compared with the general population. It is unclear whether this excess in thyroid cancer is associated with WTC-related exposures or if instead there is an over-diagnosis of malignant thyroid cancer among WTC [...] Read more.
Thyroid cancer incidence is higher in World Trade Center (WTC) responders compared with the general population. It is unclear whether this excess in thyroid cancer is associated with WTC-related exposures or if instead there is an over-diagnosis of malignant thyroid cancer among WTC first responders due to enhanced surveillance and physician bias. To maximize diagnostic yield and determine the false positive rate for malignancy, the histological diagnoses of thyroid cancer tumors from WTC responders and age, gender, and histology matched non-WTC thyroid cancer cases were evaluated using biomarkers of malignancy. Using a highly accurate panel of four biomarkers that are able to distinguish benign from malignant thyroid cancer, our results suggest that over-diagnosis by virtue of misdiagnosis of a benign tumor as malignant does not explain the increased incidence of thyroid cancer observed in WTC responders. Therefore, rather than over-diagnosis due to physician bias, the yearly screening visits by the World Trade Center Health Program are identifying true cases of thyroid cancer. Continuing regular screening of this cohort is thus warranted. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
A Quality Improvement Assessment of the Delivery of Mental Health Services among WTC Responders Treated in the Community
Int. J. Environ. Res. Public Health 2019, 16(9), 1536; https://doi.org/10.3390/ijerph16091536
Received: 28 February 2019 / Revised: 23 April 2019 / Accepted: 24 April 2019 / Published: 30 April 2019
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Abstract
The World Trade Center Health Program (WTCHP) provides mental health services through diverse service delivery mechanisms, however there are no current benchmarks to evaluate utilization or quality. This quality improvement (QI) initiative sought to examine the delivery and effectiveness of WTCHP mental health [...] Read more.
The World Trade Center Health Program (WTCHP) provides mental health services through diverse service delivery mechanisms, however there are no current benchmarks to evaluate utilization or quality. This quality improvement (QI) initiative sought to examine the delivery and effectiveness of WTCHP mental health services for World Trade Center (WTC) responders who receive care through the Northwell Health Clinical Center of Excellence (CCE), and to characterize the delivery of evidence-based treatments (EBT) for mental health (MH) difficulties in this population. Methods include an analysis of QI data from the Northwell CCE, and annual WTCHP monitoring data for all responders certified for mental health treatment. Nearly 48.9% of enrolled responders with a WTC-certified diagnosis utilized treatment. The majority of treatment delivered was focused on WTC-related conditions. There was significant disagreement between provider-reported EBT use and independently-evaluated delivery of EBT (95.6% vs. 54.8%, p ≤ 0.001). EBT delivery was associated with a small decrease in Posttraumatic Stress Disorder (PTSD) symptoms over time. Providers engaged in the process of data collection, but there were challenges with adherence to outcome monitoring and goal setting. Data from this report can inform continued QI efforts in the WTCHP, as well as the implementation and evaluation of EBT. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Metabolic Syndrome Biomarkers of World Trade Center Airway Hyperreactivity: A 16-Year Prospective Cohort Study
Int. J. Environ. Res. Public Health 2019, 16(9), 1486; https://doi.org/10.3390/ijerph16091486
Received: 19 March 2019 / Revised: 16 April 2019 / Accepted: 18 April 2019 / Published: 26 April 2019
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Abstract
Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N [...] Read more.
Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N = 7486 World Trade Center (WTC)-exposed male firefighters from 11 September 2001 (9/11) until 1 August 2017 and investigated N = 539 with newly developed AHR for clinical biomarkers of MetSyn and compared them to the non-AHR group. Male firefighters with normal lung function and no AHR pre-9/11 who had blood drawn from 9 September 2001–24 July 2002 were assessed. World Trade Center-Airway Hyperreactivity (WTC-AHR) was defined as either a positive bronchodilator response (BDR) or methacholine challenge test (MCT). The electronic medical record (EMR) was queried for their MetSyn characteristics (lipid profile, body mass index (BMI), glucose), and routine clinical biomarkers (such as complete blood counts). We modeled the association of MetSyn characteristics at the first post-9/11 exam with AHR. Those with AHR were significantly more likely to be older, have higher BMIs, have high intensity exposure, and have MetSyn. Smoking history was not associated with WTC-AHR. Those present on the morning of 9/11 had 224% increased risk of developing AHR, and those who arrived in the afternoon of 9/11 had a 75.9% increased risk. Having ≥3 MetSyn parameters increased the risk of WTC-AHR by 65.4%. Co-existing MetSyn and high WTC exposure are predictive of future AHR and suggest that systemic inflammation may be a contributor. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Time to Onset of Paresthesia Among Community Members Exposed to the World Trade Center Disaster
Int. J. Environ. Res. Public Health 2019, 16(8), 1429; https://doi.org/10.3390/ijerph16081429
Received: 12 March 2019 / Revised: 11 April 2019 / Accepted: 12 April 2019 / Published: 22 April 2019
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Abstract
We examined whether time to onset of paresthesia was associated with indicators of severity of World Trade Center (WTC) exposure. We analyzed data from 3411 patients from the Bellevue Hospital—WTC Environmental Health Center. Paresthesia was defined as present if the symptom occurred in [...] Read more.
We examined whether time to onset of paresthesia was associated with indicators of severity of World Trade Center (WTC) exposure. We analyzed data from 3411 patients from the Bellevue Hospital—WTC Environmental Health Center. Paresthesia was defined as present if the symptom occurred in the lower extremities with frequency “often” or “almost continuous.” We plotted hazard functions and used the log-rank test to compare time to onset of paresthesia between different exposure groups. We also used Cox regression analysis to examine risk factors for time-to-paresthesia after 9/11/2001 and calculate hazard ratios adjusted for potential confounders. We found significantly elevated hazard ratios for paresthesia for (a) working in a job that required cleaning of WTC dust in the workplace; and (b) being heavily exposed to WTC dust on September 11, 2001, after adjusting for age, race/ethnicity, depression, anxiety, post-traumatic stress disorder, and body mass index. These observational data are consistent with the hypothesis that exposure to WTC dust or some other aspect of cleaning WTC dust in the workplace, is associated with neuropathy and paresthesia. Further neurological evaluations of this and other WTC-exposed populations is warranted. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Bronchodilator Response Predicts Longitudinal Improvement in Small Airway Function in World Trade Center Dust Exposed Community Members
Int. J. Environ. Res. Public Health 2019, 16(8), 1421; https://doi.org/10.3390/ijerph16081421
Received: 27 February 2019 / Revised: 4 April 2019 / Accepted: 17 April 2019 / Published: 20 April 2019
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Abstract
The evolution of lung function, including assessment of small airways, was assessed in individuals enrolled in the World Trade Center Environmental Health Center (WTC-EHC). We hypothesized that a bronchodilator response at initial evaluation shown by spirometry or in small airways, as measured by [...] Read more.
The evolution of lung function, including assessment of small airways, was assessed in individuals enrolled in the World Trade Center Environmental Health Center (WTC-EHC). We hypothesized that a bronchodilator response at initial evaluation shown by spirometry or in small airways, as measured by forced oscillation technique (FOT), would be associated with improvement in large and small airway function over time. Standardized longitudinal assessment included pre and post bronchodilator (BD) spirometry (forced vital capacity, FVC; forced expiratory volume in 1 second, FEV1) and FOT (resistance at 5 Hz, R5; resistance at 5 minus 20 Hz, R5–20). Longitudinal changes were assessed using linear mixed-effects modelling with adjustment for potential confounders (median follow-up 2.86 years; 95% measurements within 4.9 years). Data demonstrated: (1) parallel improvement in airflow and volume measured by spirometry and small airway function (R5 and R5–20) measured by FOT; (2) the magnitude of longitudinal improvement was tightly linked to the initial BD response; and (3) longitudinal values for small airway function on FOT were similar to residual abnormality observed post BD at initial visit. These findings suggest presence of reversible and irreversible components of small airway injury that are identifiable at initial presentation. These results have implications for treatment of isolated small airway abnormalities that can be identified by non-invasive effort independent FOT particularly in symptomatic individuals with normal spirometry indices. This study underscores the need to study small airway function to understand physiologic changes over time following environmental and occupational lung injury. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessFeature PaperArticle
A Cognitive Reserve and Social Support-Focused Latent Class Analysis to Predict Self-Reported Confusion or Memory Loss among Middle-Aged World Trade Center Health Registry Enrollees
Int. J. Environ. Res. Public Health 2019, 16(8), 1401; https://doi.org/10.3390/ijerph16081401
Received: 25 February 2019 / Revised: 11 April 2019 / Accepted: 13 April 2019 / Published: 18 April 2019
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Abstract
The World Trade Center Health Registry includes 9/11 survivors who have been surveyed about their health conditions over time. The prevalence of posttraumatic stress disorder (PTSD) remains high among the cohort and is a risk factor for cognitive impairment or dementia. We thus [...] Read more.
The World Trade Center Health Registry includes 9/11 survivors who have been surveyed about their health conditions over time. The prevalence of posttraumatic stress disorder (PTSD) remains high among the cohort and is a risk factor for cognitive impairment or dementia. We thus sought to examine the degree to which confusion or memory loss (CML)—potential symptoms of cognitive decline—are occurring among enrollees aged 35–64 years. Cognitive reserve theory suggests that higher levels of education and engaging in cognitively challenging activities can create stronger neural connections, offering protection against cognitive decline. We hypothesized that enrollees with less cognitive reserve would be more likely to report CML. In this study, we: (1) estimated the incidence of CML in our study sample; (2) identified indicators of cognitive reserve (e.g., indicators of educational attainment, social support); and (3) determined whether CML is associated with cognitive reserve level, stratified by PSTD status. First, we described demographics of the study sample (n = 14,574) and probable PTSD status, also stratifying by CML. Next, we conducted a latent class analysis on two groups: those with probable PTSD and those without probable PTSD, creating classes with varying cognitive reserve levels. Finally, using adjusted log binomial models, we predicted risk of CML based on cognitive reserve level. The probable PTSD group (n = 1213) and not probable PTSD group (n = 13,252) each had four latent classes: low, medium-low, medium-high, and high cognitive reserve. In the probable PTSD model, compared to the high cognitive reserve class, those with medium-low cognitive reserve were 35% more likely to report CML (relative risk (RR) = 1.4, 95% confidence interval (CI): 1.1, 1.7). Among the not probable PTSD group, those with low and medium levels of cognitive reserve were significantly more likely to report CML (RR = 1.8 and 1.4, respectively). Overall, those with less cognitive reserve were more likely to report CML regardless of PTSD status. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Unmet Mental Health Care Needs among Asian Americans 10–11 Years After Exposure to the World Trade Center Attack
Int. J. Environ. Res. Public Health 2019, 16(7), 1302; https://doi.org/10.3390/ijerph16071302
Received: 28 February 2019 / Revised: 2 April 2019 / Accepted: 5 April 2019 / Published: 11 April 2019
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Abstract
This study investigated the prevalence of unmet mental health care needs (UMHCN) and their associated factors among 2344 Asian Americans directly exposed to the World Trade Center (WTC) attack 10–11 years afterwards. Given the pervasive underutilization of mental health services among Asians, their [...] Read more.
This study investigated the prevalence of unmet mental health care needs (UMHCN) and their associated factors among 2344 Asian Americans directly exposed to the World Trade Center (WTC) attack 10–11 years afterwards. Given the pervasive underutilization of mental health services among Asians, their subjective evaluation of unmet needs could provide more nuanced information on disparities of service. We used the WTC Health Registry data and found that 12% of Asian Americans indicated UMHCN: 69% attributing it to attitudinal barriers, 36% to cost barriers, and 29% to access barriers. Among all the factors significantly related to UMHCN in the logistic model, disruption of health insurance in the past year had the largest odds ratio (OR = 2.37, 95% confidence interval: 1.61–3.48), though similar to functional impairment due to mental disorders. Post-9/11 mental health diagnosis, probable mental disorder and ≥14 poor mental health days in the past month were also associated with greater odds of UMHCN, while greater social support was associated with lower odds. Results suggest that continued outreach efforts to provide mental health education to Asian communities to increase knowledge about mental illness and treatment options, reduce stigmatization of mental illness, and offer free mental health services are crucial to address UMHCN. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Clinical Evaluation of Sarcoidosis in Community Members with World Trade Center Dust Exposure
Int. J. Environ. Res. Public Health 2019, 16(7), 1291; https://doi.org/10.3390/ijerph16071291
Received: 28 February 2019 / Revised: 2 April 2019 / Accepted: 4 April 2019 / Published: 10 April 2019
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Abstract
Background: Sarcoidosis is a granulomatous disease involving intrathoracic and extrathoracic organs. Genetic and environmental factors, such as exposure to World-Trade Center (WTC) dust after 9/11, may play a role in clinical presentation. Characterization of sarcoidosis in community members with exposure to the [...] Read more.
Background: Sarcoidosis is a granulomatous disease involving intrathoracic and extrathoracic organs. Genetic and environmental factors, such as exposure to World-Trade Center (WTC) dust after 9/11, may play a role in clinical presentation. Characterization of sarcoidosis in community members with exposure to the WTC dust can provide further insight into the relationship between environmental exposure and sarcoidosis. Methods: Patients with documented sarcoidosis were identified in the WTC Environmental Health Center (EHC), a treatment program for community members. Demographic and clinical data were collected from standardized questionnaires and chart review. Organ involvement was assessed with a standard instrument. Results: Among patients in the WTC EHC, 87 were identified with sarcoidosis after 9/11. Sarcoidosis cases were more likely African-American, local workers, and had more respiratory symptoms, compared with non-sarcoidosis WTC EHC patients. Many (46%) had ≥ Scadding stage 3 on chest imaging, and had reduced lung function measures. Extrathoracic involvement was identified in 33/87 (38%) with a diversity of organs involved. Conclusions: WTC-exposed sarcoidosis in community members is often characterized by severe pulmonary disease and a high rate of diverse extrathoracic involvement. Further analysis is required to characterize the course of disease progression or resolution. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Increased Incidence of Thyroid Cancer among World Trade Center First Responders: A Descriptive Epidemiological Assessment
Int. J. Environ. Res. Public Health 2019, 16(7), 1258; https://doi.org/10.3390/ijerph16071258
Received: 20 February 2019 / Revised: 20 March 2019 / Accepted: 4 April 2019 / Published: 9 April 2019
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Abstract
An increased incidence of thyroid cancer among 9/11 rescue workers has been reported, the etiology of which remains unclear but which may, at least partly, be the result of the increased medical surveillance this group undergoes. This study aimed to investigate thyroid cancer [...] Read more.
An increased incidence of thyroid cancer among 9/11 rescue workers has been reported, the etiology of which remains unclear but which may, at least partly, be the result of the increased medical surveillance this group undergoes. This study aimed to investigate thyroid cancer in World Trade Center (WTC) responders by looking at the demographic data and questionnaire responses of thyroid cancer cases from the Mount Sinai WTC Health Program (WTCHP). WTCHP thyroid cancer tumors were of a similar size (p = 0.4), and were diagnosed at a similar age (p = 0.2) compared to a subset of thyroid cancer cases treated at Mount Sinai without WTC exposure. These results do not support the surveillance bias hypothesis, under which smaller tumors are expected to be diagnosed at earlier ages. WTCHP thyroid cancer cases also reported a past history of radiation exposure and a family history of thyroid conditions at lower rates than expected, with higher than expected rates of previous cancer diagnoses, family histories of other cancers, and high Body Mass Indexes (BMIs). Further research is needed to better understand the underlying risk factors that may play a role in the development of thyroid cancer in this group. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
The Association between Health Conditions in World Trade Center Responders and Sleep-Related Quality of Life and Sleep Complaints
Int. J. Environ. Res. Public Health 2019, 16(7), 1229; https://doi.org/10.3390/ijerph16071229
Received: 27 February 2019 / Revised: 22 March 2019 / Accepted: 3 April 2019 / Published: 6 April 2019
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Abstract
Background: World Trade Center (WTC) dust-exposed subjects have multiple comorbidities that affect sleep. These include obstructive sleep apnea (OSA), chronic rhinosinusitis (CRS), gastroesophageal-reflux disorder (GERD) and post-traumatic stress disorder (PTSD). We examined the impact of these conditions to sleep-related outcomes. Methods: Demographics, [...] Read more.
Background: World Trade Center (WTC) dust-exposed subjects have multiple comorbidities that affect sleep. These include obstructive sleep apnea (OSA), chronic rhinosinusitis (CRS), gastroesophageal-reflux disorder (GERD) and post-traumatic stress disorder (PTSD). We examined the impact of these conditions to sleep-related outcomes. Methods: Demographics, co-morbidities and symptoms were obtained from 626 WTC (109F/517M), 33–87years, BMI = 29.96 ± 5.53 kg/m2) subjects. OSA diagnosis was from a 2-night home sleep test (ARESTM). Subjective sleep quality, sleep-related quality of life (QOL, Functional Outcomes of Sleep Questionnaire), excessive daytime sleepiness (Epworth Sleepiness Scale), sleep duration and sleep onset and maintenance complaints were assessed. Results: Poor sleep quality and complaints were reported by 19–70% of subjects and average sleep duration was 6.4 h. 74.8% of subjects had OSA. OSA diagnosis/severity was not associated with any sleep-related outcomes. Sleep duration was lower in subjects with all conditions (p < 0.05) except OSA. CRS was a significant risk factor for poor sleep-related QOL, sleepiness, sleep quality and insomnia; PTSD for poor sleep-related QOL and insomnia; GERD for poor sleep quality. These associations remained significant after adjustment for, age, BMI, gender, sleep duration and other comorbidities. Conclusions: Sleep complaints are common and related to several health conditions seen in WTC responders. Initial interventions in symptomatic patients with both OSA and comorbid conditions may need to be directed at sleep duration, insomnia or the comorbid condition itself, in combination with intervention for OSA. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Longitudinal Change of PTSD Symptoms in Community Members after the World Trade Center Destruction
Int. J. Environ. Res. Public Health 2019, 16(7), 1215; https://doi.org/10.3390/ijerph16071215
Received: 1 March 2019 / Revised: 1 April 2019 / Accepted: 3 April 2019 / Published: 4 April 2019
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Abstract
The World Trade Center (WTC) Environmental Health Center (EHC) is a treatment program for community members with exposure to the 9/11 terrorist attack and its physical and emotional aftermath. Compared to the general responders program, the WTC EHC is diverse with equal gender [...] Read more.
The World Trade Center (WTC) Environmental Health Center (EHC) is a treatment program for community members with exposure to the 9/11 terrorist attack and its physical and emotional aftermath. Compared to the general responders program, the WTC EHC is diverse with equal gender distribution, representation of many races and ethnicities, and a wide range of social economic status. Patients in the WTC EHC were initially enrolled for physical symptoms, most of which were respiratory, however a large portion of the enrollees scored positive for probable posttraumatic stress disorder (PTSD). In this paper we identify patient characteristics associated with probable PTSD. We also determine the characteristics associated with the longitudinal change of PTSD symptoms, including persistence and remittance, using the widely used Posttraumatic Check List-17 (PCL) cut-off value of 44, as well as changes in PCL total score and symptom cluster scores in patients of Low and High PTSD symptom severity. Few patients with elevated scores achieved a score below 44. However, longitudinal improvement in PCL score at follow-up was identified for patients with High PTSD scores (PCL > 57.5). Changes in PCL symptom clusters differed between those with High and Low PCL scores. These data suggest improvement over time in PCL score that differs depending on the severity of the score and variable responses in the PCL symptom clusters. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Impact of Health on Early Retirement and Post-Retirement Income Loss among Survivors of the 11 September 2001 World Trade Center Disaster
Int. J. Environ. Res. Public Health 2019, 16(7), 1177; https://doi.org/10.3390/ijerph16071177
Received: 28 February 2019 / Revised: 27 March 2019 / Accepted: 29 March 2019 / Published: 2 April 2019
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Abstract
The health consequences of the 9/11 World Trade Center (WTC) terrorist attacks are well documented, but few studies have assessed the disaster’s impact on employment among individuals exposed to the disaster. We examined the association between 9/11-related health conditions and early retirement among [...] Read more.
The health consequences of the 9/11 World Trade Center (WTC) terrorist attacks are well documented, but few studies have assessed the disaster’s impact on employment among individuals exposed to the disaster. We examined the association between 9/11-related health conditions and early retirement among residents and workers who resided and/or worked near the WTC site on 9/11, and the association between such conditions and post-retirement income loss. The study included 6377 residents and/or area workers who completed the WTC Health Registry longitudinal health surveys in 2003–2004 and 2006–2007, and the 2017–2018 Health and Employment Survey. Logistic regression models were used to examine the associations. We found that 9/11-related health conditions were significantly associated with the likelihood of early retirement. Residents and/or area workers with more physical health conditions, especially when comorbid with posttraumatic stress disorder (PTSD), were more likely to retire before age 60 than those with no conditions. For retirees, having PTSD or PTSD comorbid with any number of physical conditions increased the odds of reporting substantial post-retirement income loss. Disaster-related outcomes can negatively impact aging individuals in the form of early retirement and income loss. Long-term effects of major disasters must continue to be studied. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Handgrip Strength of World Trade Center (WTC) Responders: The Role of Re-Experiencing Posttraumatic Stress Disorder (PTSD) Symptoms
Int. J. Environ. Res. Public Health 2019, 16(7), 1128; https://doi.org/10.3390/ijerph16071128
Received: 18 February 2019 / Revised: 18 March 2019 / Accepted: 26 March 2019 / Published: 29 March 2019
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Abstract
Background: This study sought to examine whether handgrip strength (HGS), a measure of muscle strength and a biomarker of aging, was associated with post-traumatic stress disorder (PTSD) in a cohort of World Trade Center (WTC) responders at midlife. Methods: HGS was [...] Read more.
Background: This study sought to examine whether handgrip strength (HGS), a measure of muscle strength and a biomarker of aging, was associated with post-traumatic stress disorder (PTSD) in a cohort of World Trade Center (WTC) responders at midlife. Methods: HGS was assessed utilizing a computer-assisted hand dynamometer administered to a consecutive sample of men and women (n = 2016) who participated in rescue and recovery efforts following the World Trade Center (WTC) attacks and subsequently attended monitoring appointments in Long Island, NY. PTSD symptom severity and depressive symptoms were assessed using the PTSD specific-trauma checklist (PCL-S) and the Patient Health Questionnaire (PHQ-9). General linear models were used to examine the association of WTC-related PTSD with HGS after adjusting for confounders. Results: The sample was at midlife (mean age = 53.3) when assessed, and 91.3% were men. Nearly 10% of the sample had probable PTSD (PCL ≥ 44) with concomitant depression (PHQ ≥ 10), while 5.1% had probable PTSD without depression. Average HGS was 57.4 lbs. (95% confidence interval (95% CI): 56.6–58.1) among men and 36.1 lbs. (95% CI = 33.8–38.5) among women. Mean HGS of those with probable PTSD with concomitant depression was lower (45.9 lbs., 95% CI = 43.6–48.2) than responders with only PTSD (49.1 lbs., 95% CI = 46.0–52.4) and those without PTSD or depression (57.5 lbs., 95% CI = 56.2–57.8). Subdomain analyses of PTSD symptoms revealed that re-experiencing symptoms at enrollment (p = 0.003) was associated with lower HGS after adjusting for depressive symptoms and other confounders. Discussion: Results suggested that higher WTC-related PTSD symptom severity was associated with lower HGS. Results support ongoing work suggesting that PTSD may be associated with more rapid physical aging. The potential for developing interventions that might simultaneously improve physical and mental health in the aftermath of trauma may be considered. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
An Assessment of Long-Term Physical and Emotional Quality of Life of Persons Injured on 9/11/2001
Int. J. Environ. Res. Public Health 2019, 16(6), 1054; https://doi.org/10.3390/ijerph16061054
Received: 15 February 2019 / Revised: 20 March 2019 / Accepted: 21 March 2019 / Published: 23 March 2019
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Abstract
Fifteen years after the disaster, the World Trade Center Health Registry (Registry) conducted The Health and Quality of Life Survey (HQoL) assessing physical and mental health status among those who reported sustaining an injury on 11 September 2001 compared with non-injured persons. Summary [...] Read more.
Fifteen years after the disaster, the World Trade Center Health Registry (Registry) conducted The Health and Quality of Life Survey (HQoL) assessing physical and mental health status among those who reported sustaining an injury on 11 September 2001 compared with non-injured persons. Summary scores derived from the Short Form-12 served as study outcomes. United States (US) population estimates on the Physical Component Score (PCS-12) and Mental Component Score (MCS-12) were compared with scores from the HQoL and were stratified by Post-traumatic Stress Disorder (PTSD) and injury status. Linear regression models were used to estimate the association between both injury severity and PTSD and PCS-12 and MCS-12 scores. Level of injury severity and PTSD history significantly predicted poorer physical health (mean PCS-12). There was no significant difference between injury severity level and mental health (mean MCS-12). Controlling for other factors, having PTSD symptoms after 9/11 predicted a nearly 10-point difference in mean MCS-12 compared with never having PTSD. Injury severity and PTSD showed additive effects on physical and mental health status. Injury on 9/11 and a PTSD history were each associated with long-term decrements in physical health status. Injury did not predict long-term decrements in one’s mental health status. Although it is unknown whether physical wounds of the injury healed, our results suggest that traumatic injuries appear to have a lasting negative effect on perceived physical functioning. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
Pulmonary Fibrosis among World Trade Center Responders: Results from the WTC Health Registry Cohort
Int. J. Environ. Res. Public Health 2019, 16(5), 825; https://doi.org/10.3390/ijerph16050825
Received: 12 February 2019 / Revised: 1 March 2019 / Accepted: 4 March 2019 / Published: 7 March 2019
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Abstract
Dust created by the collapse of the World Trade Center (WTC) towers on 9/11 included metals and toxicants that have been linked to an increased risk of pulmonary fibrosis (PF) in the literature. Little has been reported on PF among WTC responders. This [...] Read more.
Dust created by the collapse of the World Trade Center (WTC) towers on 9/11 included metals and toxicants that have been linked to an increased risk of pulmonary fibrosis (PF) in the literature. Little has been reported on PF among WTC responders. This report used self-reported physician diagnosis of PF with an unknown sub-type to explore the association between levels of WTC dust exposure and PF. We included 19,300 WTC responders, enrolled in the WTC Health Registry in 2003–2004, who were followed for 11 years from 2004 to 2015. Exposure was defined primarily by intensity and duration of exposure to WTC dust/debris and work on the debris pile. Stratified Cox regression was used to assess the association. We observed 73 self-reported physician-diagnosed PF cases, with a PF incidence rate of 36.7/100,000 person-years. The adjusted hazard ratio (AHR) of PF was higher in those with a medium (AHR = 2.5, 95% CI = 1.1–5.8) and very high level of exposure (AHR = 4.5, 95% CI = 2.0–10.4), compared to those with low exposure. A test for exposure—response trend was statistically significant (Ptrend = 0.004). Future research on WTC dust exposure and PF would benefit from using data from multiple WTC Health Program responder cohorts for increased statistical power and clinically confirmed cases. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Sarcoid-Like Granulomatous Disease: Pathologic Case Series in World Trade Center Dust Exposed Rescue and Recovery Workers
Int. J. Environ. Res. Public Health 2019, 16(5), 815; https://doi.org/10.3390/ijerph16050815
Received: 23 January 2019 / Revised: 22 February 2019 / Accepted: 26 February 2019 / Published: 6 March 2019
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Abstract
Sarcoid-like granulomatous diseases (SGD) have been previously identified in cohorts of World Trade Center (WTC) dust-exposed individuals. In the present studies, we analyzed lung and/or lymph node biopsies from patients referred to our clinic with suspected WTC dust-induced lung disease to evaluate potential [...] Read more.
Sarcoid-like granulomatous diseases (SGD) have been previously identified in cohorts of World Trade Center (WTC) dust-exposed individuals. In the present studies, we analyzed lung and/or lymph node biopsies from patients referred to our clinic with suspected WTC dust-induced lung disease to evaluate potential pathophysiologic mechanisms. Histologic sections of lung and/or lymph node samples were analyzed for markers of injury, oxidative stress, inflammation, fibrosis, and epigenetic modifications. Out of seven patients examined, we diagnosed four with SGD and two with pulmonary fibrosis; one was diagnosed later with SGD at another medical facility. Patients with SGD were predominantly white, obese men, who were less than 50 years old and never smoked. Cytochrome b5, cytokeratin 17, heme oxygenase-1, lipocalin-2, inducible nitric oxide synthase, cyclooxygenase 2, tumor necrosis factor α, ADP-ribosylation factor-like GTPase 11, mannose receptor-1, galectin-3, transforming growth factor β, histone-3 and methylated histone-3 were identified in lung and lymph nodes at varying levels in all samples examined. Three of the biopsy samples with granulomas displayed peri-granulomatous fibrosis. These findings are important and suggest the potential of WTC dust-induced fibrotic sarcoid. It is likely that patient demographics and/or genetic factors influence the response to WTC dust injury and that these contribute to different pathological outcomes. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessArticle
9/11 Residential Exposures: The Impact of World Trade Center Dust on Respiratory Outcomes of Lower Manhattan Residents
Int. J. Environ. Res. Public Health 2019, 16(5), 798; https://doi.org/10.3390/ijerph16050798
Received: 4 February 2019 / Revised: 25 February 2019 / Accepted: 28 February 2019 / Published: 5 March 2019
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Abstract
Thousands of lower Manhattan residents sustained damage to their homes following the collapse of the Twin Towers on 11 September 2001. Respiratory outcomes have been reported in this population. We sought to describe patterns of home damage and cleaning practices in lower Manhattan [...] Read more.
Thousands of lower Manhattan residents sustained damage to their homes following the collapse of the Twin Towers on 11 September 2001. Respiratory outcomes have been reported in this population. We sought to describe patterns of home damage and cleaning practices in lower Manhattan and their impacts on respiratory outcomes among World Trade Center Health Registry (WTCHR) respondents. Data were derived from WTCHR Wave 1 (W1) (9/2003–11/2004) and Wave 2 (W2) (11/2006–12/2007) surveys. Outcomes of interest were respiratory symptoms (shortness of breath (SoB), wheezing, persistent chronic cough, upper respiratory symptoms (URS)) first occurring or worsening after 9/11 W1 and still present at W2 and respiratory diseases (asthma and chronic obstructive pulmonary disease (COPD)) first diagnosed after 9/11 W1 and present at W2. We performed descriptive statistics, multivariate logistic regression and geospatial analyses, controlling for demographics and other exposure variables. A total of 6447 residents were included. Mean age on 9/11 was 45.1 years (±15.1 years), 42% were male, 45% had ever smoked cigarettes, and 44% reported some or intense dust cloud exposure on 9/11. The presence of debris was associated with chronic cough (adjusted OR (aOR) = 1.56, CI: 1.12–2.17), and upper respiratory symptoms (aOR = 1.56, CI: 1.24–1.95). A heavy coating of dust was associated with increased shortness of breath (aOR = 1.65, CI: 1.24–2.18), wheezing (aOR = 1.43, CI: 1.03–1.97), and chronic cough (aOR = 1.59, CI: 1.09–2.28). Dusting or sweeping without water was the cleaning behavior associated with the largest number of respiratory outcomes, such as shortness of breath, wheezing, and URS. Lower Manhattan residents who suffered home damage following the 9/11 attacks were more likely to report respiratory symptoms and diseases compared to those who did not report home damage. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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Open AccessFeature PaperArticle
Allergen Sensitization and Asthma Outcomes among World Trade Center Rescue and Recovery Workers
Int. J. Environ. Res. Public Health 2019, 16(5), 737; https://doi.org/10.3390/ijerph16050737
Received: 15 January 2019 / Revised: 15 February 2019 / Accepted: 22 February 2019 / Published: 1 March 2019
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Abstract
A large number of World Trade Center (WTC) rescue and recovery workers are affected by asthma. While physical and mental health comorbidities have been associated with poor asthma control in this population, the potential role of allergen sensitization is unknown. This study examined [...] Read more.
A large number of World Trade Center (WTC) rescue and recovery workers are affected by asthma. While physical and mental health comorbidities have been associated with poor asthma control in this population, the potential role of allergen sensitization is unknown. This study examined the association of indoor sensitization and exposure as a risk factor for increased asthma morbidity in WTC workers. We used data from a prospective cohort of 331 WTC workers with asthma. Sensitization to indoor allergens was assessed by measurement of antigen-specific serum immunoglobulin E (IgE) levels. We used validated tools to evaluate the exposure to indoor allergens. Asthma morbidity outcomes included level of control (Asthma Control Questionnaire, ACQ), quality of life (Asthma Quality of Life Questionnaire, AQLQ) and acute resource utilization. The prevalence of sensitization to cat, dog, mouse, dust mite, cockroach, and mold allergens were 33%, 21%, 17%, 40%, 17%, and 17%, respectively. Unadjusted and regression analyses showed no significant relationship between sensitization and increased asthma morbidity (p > 0.05 for all comparisons), except for sensitization to Aspergillus Fumigatus, cat and mouse epithelium, which were associated with decreased morbidity. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
Open AccessArticle
Characterizing Mental Health Treatment Utilization among Individuals Exposed to the 2001 World Trade Center Terrorist Attacks 14–15 Years Post-Disaster
Int. J. Environ. Res. Public Health 2019, 16(4), 626; https://doi.org/10.3390/ijerph16040626
Received: 10 January 2019 / Revised: 7 February 2019 / Accepted: 15 February 2019 / Published: 20 February 2019
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Abstract
Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, [...] Read more.
Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, none have data more than two years post-disaster. We used data from 35,629 enrollees of the WTC Health Registry, a longitudinal cohort study of those exposed to the WTC attacks, to examine predictors of counseling after 9/11, the types of practitioners seen, and the perceived helpfulness of therapy up to 15 years post-disaster. Among enrollees, 37.7% reported receiving counseling at some time after 9/11. Predictors of seeking counseling included race/ethnicity, age at 9/11, education level, exposure to the WTC attacks, other traumatic experiences, mental health symptomology, and pre-9/11 counseling. Whites and Hispanics, those who were children on 9/11, and those with high levels of exposure to the WTC attacks sought counseling soonest after 9/11. Among those who sought counseling, Blacks, Asians, and those with lower education and income were less likely to see mental health specialists and more likely to see general practitioners or religious advisors. Finally, among those who sought recent counseling, women, Blacks, those aged ≥65 years, and those with very high WTC exposures were more likely to rate their recent counseling as very helpful. This study used data up to 15 years post-disaster to document mental health treatment utilization patterns, trends, and disparities that have implications for future preparedness plans and needs assessments. Full article
(This article belongs to the Special Issue Long-Term Health Effects of the 9/11 Disaster)
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