Researchers Still Responding to Far-reaching Effects of 9/11

Troy Brown, RN

September 16, 2016

Researchers from the World Trade Center (WTC) Health Program presented their findings on Wednesday about the effects of 9/11 on responders and survivors involved in the New York City attack.

The WTC Health Program provides healthcare and monitoring for responders and survivors at the WTC, the Pentagon, and the crash site near Shanksville, Pennsylvania. The program was established by the James Zadroga 9/11 Health and Compensation Act of 2010 and has been reauthorized until 2090. In addition to providing services to individuals, the program is also collecting and analyzing data at the macro level in the 9/11 cohort and conducting research.

Responders are the emergency responders, recovery and cleanup workers, and volunteers who assisted at the WTC on September 11, 2001, and in the months after. Approximately 90,000 people responded to hazardous sites, said Laura Crowley, MD, Icahn School of Medicine at Mount Sinai, New York City. Many were nontraditional volunteers, including those working in communications, transit, or construction, and lacked formal training.

Survivors are those who were at the WTC on 9/11 and those who worked, lived, or attended school in the surrounding area on that day or the following months.

"At the New York City Fire Department [NYFD], we have approximately, in any given year, 11,500 firefighters and fire officers and approximately 3500 [emergency medical services (EMS)] workers, and on 9/11, they responded. In addition to that, there were recent and past retirees who volunteered and came to 9/11 on that day and mostly on subsequent days to help out with the effort," David J. Prezant, MD, chief medical officer at the Office of Medical Affairs for the Fire Department of the City of New York, explained.

The program has provided services to 15,706 firefighters and EMS personnel; 2292 (15%) responded on the morning of 9/11, 6848 (44%) on the afternoon of 9/11, 2746 (18%) on 9/12, 2664 (17%) from 9/13 to 9/24, and 484 (3%) from 9/25/2001 to 7/24/2002.

Multimorbidity has been the norm for responders and survivors alike, and many experienced physical injuries as well as emotional trauma.

"Toxic Brew"

Thousands of people were exposed to debris from the airplanes' impact with the towers and hazardous dust from the collapse of the WTC buildings on 9/11 and after. More than one presenter referred to this dust as a "toxic brew" that contained chrysotile asbestos, cement dust, glass fibers, lead and other heavy metals, polychlorinated biphenyls (PCBs), and toxic combustion products. People were exposed to the dust from the initial dust cloud, during clean-up of the surrounding streets and buildings or when they entered their homes to collect belongings, and later on a chronic basis when dust was stirred up in incompletely cleaned buildings. People were still being exposed to toxic fumes from burning fires through December 2001.

Some 15% of the NYFD workers were present when the WTC towers collapsed and as many as 75% were there within the first 24 to 48 hours. Only 10% consistently used a respirator on the day of the attacks and 50% used no protection at all. The remainder used either a dust mask or infrequently used a respirator. The percentage of NYFD workers who used a respirator improved slightly to 15% on 9/12 but was about 38% during the remainder of September and approximately 45% from the beginning of October until July 24, 2002. The NYFD already had a monitoring program for respiratory disorders in place before 9/11, and this has enabled researchers to compare differences from before and after 9/11.

The difficulties in exposure modeling are even more complex in the community population than they are in the responder population, Joan Reibman, MD, WTC Environmental Health Center, NYC Health+Hospitals/Bellevue, said. "When we're talking about the community population, we're really talking about the potential exposure to approximately 60,000 individuals who lived below Canal Street on 9/11, 300,000 individuals who were working, including tower evacuees on 9/11…approximately 15,000 students and some numbers of individuals who were passing by as commuters or tourists in this very busy hub at that time. So [there is the] potential for enormous exposure to a very disparate community."

There was a wide range of ages and incomes among survivors, and half were women.

As many as half of the survivors were caught in the initial dust cloud, and this exposure was later determined to be a risk factor for developing post-traumatic stress disorder (PTSD) (adjusted odds ratio, 1.87; 95% confidence interval, 1.64 - 2.14; P < .0001). Those who were exposed to the dust cloud also have an increased risk for wheezing 2 or more days per week (adjusted odds ratio, 1.32; 95% confidence interval, 1.15 - 1.51; P < .0001).

Others suffered injuries or burns escaping from the towers and surrounding buildings.

Physical, Mental Health "Opposite Sides of the Same Coin"

A common theme throughout the daylong meeting was the interplay between physical health and mental health. Evelyn Bromet, PhD, from the Stony Brook University School of Medicine, called physical and mental health "opposite sides of the same coin." Physical ailments continue to trigger painful memories and emotional distress in those involved in 9/11. Overall, WTC exposure doubled the risk of developing PTSD. This effect was more pronounced in civilians compared with responders, although the effect among NYFD workers caught in the dust cloud was similar to that in civilians. The effect was stronger among nontraditional responders compared with traditional responders.

At the same time, PTSD is strongly linked to new-onset and persistent medical conditions including respiratory symptoms, diabetes, and autoimmune diseases.

Mental health consequences go beyond PTSD, and include depression, health anxiety, and grief, Dr Bromet explained, adding that depression may not get as much attention as PTSD.

Health surveillance programs after disasters have only begun to monitor mental health and physical health simultaneously since 9/11, and the 9/11 monitoring programs have been "game changers," Dr Bromet said.

When analyzing data from disasters, it is important to consider the phase during which the data were collected, she added. The short-term phase involves the days after a disaster, the intermediate phase includes the ensuing weeks and months, and the long-term phase includes the months and years after a disaster. These phases overlap and the long-term phase is open-ended because it never truly ends.

Problems Associated With 9/11 Injuries

Injuries were prevalent on 9/11, and many of the 9/11 studies use injuries as a predictor. Injuries are a major risk factor for developing PTSD and physical ailments such as cardiovascular disease. A report of an injury is the "one and only risk factor that was associated with dying from substance abuse," said Robert Brackbill, PhD, MPH, director of research, World Trade Center Health Registry. Dr Brackbill presented findings from a qualitative analysis of 9/11 injury that included data from 34 individuals who were injured on that day. The researchers will begin the second phase of this study in January 2017, in which they will explore factors involved with healing from the effects of 9/11.

The investigators wanted to avoid causing distress to study participants resulting from recalling traumatic events, so they recruited those with no PTSD first to see how they responded to the interview. They developed a protocol whereby the interviewer could identify and ameliorate distress during the interview and help the patient obtain assistance if necessary.

Individuals who were injured on 9/11 continue to experience effects from their experiences on that day. Those who reported functional impairment said they were no longer able to do things they had previously found enjoyable, including working out, playing sports, and participating in outdoor activities with their families. They also avoided certain situations including flying in airplanes, riding the subway, and being in Manhattan. Many experienced social isolation resulting from an aversion to being in crowds and avoiding going out with their friends.

At the same time, many said their families were a source of emotional support for them. They also derived support from friends, church attendance, mental health therapy, and volunteer work. Several participants said they only felt comfortable discussing the events of 9/11 with other 9/11 survivors.

The economic effects were also significant in these individuals and included job loss resulting from disability and early retirement, retirement, and company downsizing. Some lost their homes as a result.

Several participants reported self-medicating with alcohol or other drugs.

Current and Future 9/11 Research

Major areas of research interest include characterizing physical and mental health sequelae of 9/11 exposures, exploring health and development alterations in children who were exposed to 9/11, improving disaster-related healthcare services, and exploring work-related issues.

Research needs to capitalize on the various social media available, which will require some researchers to develop new skills, said Dori B. Reissman, MD, MPH, associate administrator and medical director, and chief medical officer of the WTC Health Program. Social media makes information available much more quickly than in the past.

She described improvements to the program's website, which she said is "highly interactive" and includes YouTube videos featuring researchers describing their studies.

Dr Reissman highlighted the Medscape for Distance Learning continuing medical education (CME) course that is available online.

"We attempted to…take some of the information from the very people who spoke with you today and move it into a wonderful disseminator, which is Medscape. They reach clinicians very, very well…physicians, nurses, perhaps some other allied health professions," she explained.

She said they are attempting to make this CME offering available long-term through the Centers for Disease Control and Prevention. "This is a way to reach all of the folks outside of the immediate cities that were affected," she said.

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