Long-Term Lower Respiratory Symptoms among World Trade Center Health Registry Enrollees Following Hurricane Sandy.

Several studies showed an association between lower respiratory tract symptoms (LRS) and exposure to the 9/11 terrorist attack. However, few studies have examined the long-term impact of natural disasters on those with prior respiratory distress. The present study aims to assess the impact of Hurricane Sandy on persistent LRS among people exposed to the World Trade Center (WTC) terrorist attack. The analytic sample consisted of WTC Health Registry enrollees who completed survey waves 1, 3, and 4 and the Hurricane Sandy Survey and did not report LRS before the WTC terrorist attack. The log binomial was used to assess the association between the impact of Hurricane Sandy and persistent LRS. Of 3277 enrollees, 1111 (33.9%) reported persistent LRS post-Sandy. Participants of older age, males, lower household income, current smokers, and those with previous asthma were more likely to report persistent LRS. In separate adjusted models, multiple Sandy-related inhalation exposures (relative risk (RR): 1.2, 95% CI: 1.06-1.37), Sandy-related PTSD (RR: 1.27, 95% CI: 1.15-1.4), and Sandy LRS (RR: 1.64, 95% CI: 1.48-1.81) were associated with persistent LRS post-Sandy. Our findings suggest that respiratory protection is important for everyone performing reconstruction and clean-up work after a natural disaster, particularly among those with previous respiratory exposures.

Post-Traumatic Growth and Quality of Life among World Trade Center Health Registry Enrollees 16 Years after 9/11.

A recent study of World Trade Center Health Registry enrollees found that about one-third experienced post-traumatic growth (PTG) in the wake of the 9/11 attacks and that PTG was associated with social support and social integration. However, the implications of PTG for the enrollees' overall quality of life are unknown. The present study investigated the prevalence of PTG and its association with the SF-12 physical and mental functioning quality of life scales in a sample of 4760 enrollees from the Registry's Health and Quality of Life Study (HQoL) who completed the first four surveys, were older than 18 on 9/11, reported English as their primary spoken language, and provided consistent self-report of 9/11 physical injury at the Registry's baseline and HQoL surveys. We employed multivariable linear regression to evaluate the association between PTG and the SF-12 physical and mental scales, controlling for sociodemographic and other variables. We found that 31% of the sample enrollees experienced PTG and that PTG exhibited a clinically and statistically significant association with the SF-12 mental scale but not the physical scale (physical: b = 0.15 (-0.45, 0.75), mental: b = 3.61 (2.85, 4.37)). Those who were physically injured during 9/11 showed larger improvements in mental functioning than those who were not. PTG has implications for the overall mental quality of life that should be further investigated.

Trajectories of posttraumatic stress symptoms following the September 11, 2001, terrorist attacks: A comparison of two modeling approaches.

Several studies have analyzed longitudinal data on posttraumatic stress symptoms (PTSS) from individuals who were proximal to the September 11, 2001, terrorist attacks (9/11) in an attempt to identify different trajectories of mental health in the years following mass trauma. The results of these studies have been heterogeneous, with researchers who used latent growth mixture modeling (LGMM) tending to identify four trajectories and those who used group-based trajectory modeling (GBTM) identifying five to seven trajectories. Given that no study has applied both GBTM and LGMM to their data, it remains unknown which modeling approach and what number of trajectories best fit post-9/11 PTSS data. The present study aimed to address that question by applying both LGMM and GBTM to data from the largest sample of survivors to date, comprising 37,545 New York City community members. When analyzing four waves of PTSS, reflecting participants' mental health up to 15 years post-9/11, LGMM fit the data better than GBTM. Our optimal solution consisted of four trajectories: low-stable (72.2% of the sample), decreasing (12.8%), increasing (9.5%), and high-stable (5.5%) symptoms. Covariate analyses indicated that economic factors (i.e., having a household income less than $25,000 and experiencing job loss due to 9/11) increased the odds of belonging to the high-stable symptom trajectory group to the greatest degree, ORs = 4.93-6.08. The results suggest that providing financial support, including affordable mental health care, could be an important intervention in the wake of future mass traumatic events.

Trajectories of psychological distress among individuals exposed to the 9/11 World Trade Center disaster.

BACKGROUND: Individuals present in lower Manhattan during the 9/11 World Trade Center (WTC) disaster suffered from significant physical and psychological trauma. Studies of longitudinal psychological distress among those exposed to trauma have been limited to relatively short durations of follow-up among smaller samples. METHODS: The current study longitudinally assessed heterogeneity in trajectories of psychological distress among WTC Health Registry enrollees - a prospective cohort health study of responders, students, employees, passersby, and residents in the affected area (N = 30 839) - throughout a 15-year period following the WTC disaster. Rescue/recovery status and exposure to traumatic events of 9/11, as well as sociodemographic factors and health status, were assessed as risk factors for trajectories of psychological distress. RESULTS: Five psychological distress trajectory groups were found: none-stable, low-stable, moderate-increasing, moderate-decreasing, and high-stable. Of the study sample, 78.2% were classified as belonging to the none-stable or low-stable groups. Female sex, being younger at the time of 9/11, lower education and income were associated with a higher probability of being in a greater distress trajectory group relative to the none-stable group. Greater exposure to traumatic events of 9/11 was associated with a higher probability of a greater distress trajectory, and community members (passerby, residents, and employees) were more likely to be in greater distress trajectory groups - especially in the moderate-increasing [odds ratios (OR) 2.31 (1.97-2.72)] and high-stable groups [OR 2.37 (1.81-3.09)] - compared to the none-stable group. CONCLUSIONS: The current study illustrated the heterogeneity in psychological distress trajectories following the 9/11 WTC disaster, and identified potential avenues for intervention in future disasters.

Stroke hospitalizations, posttraumatic stress disorder, and 9/11-related dust exposure: Results from the World Trade Center Health Registry.

BACKGROUND: Few studies have examined the association between disaster-related factors and stroke by subtype or number. We investigated the association between 9/11-related posttraumatic stress disorder (PTSD), dust exposure, and stroke subtype as well as recurrent strokes. METHODS: The study included 29,012 individuals enrolled in the World Trade Center Health Registry. Stroke cases were obtained by matching Registry enrollees to the New York State Department of Health's discharge records for inpatient visits between 2000 and 2016. Cox proportional hazards regression models were performed to examine the association between 9/11-related risk factors and stroke by subtype. Multinomial logistic regression models were conducted to assess the associations between the same risk factors and the number of stroke hospitalizations. RESULTS: Having PTSD significantly increased the risk of developing ischemic and hemorrhagic stroke, with adjusted hazards ratios (AHRs) of 1.64 (95% confidence interval [CI]: 1.28-2.10) and 1.73 (95% CI: 1.10-2.71), respectively. The point estimate for dust cloud exposure, although not significant statistically, suggested an increased risk of ischemic stroke (AHR = 1.20, 95% CI: 0.96-1.50). PTSD was significantly associated with recurrent strokes with an adjusted odds ratio of 1.79 (95% CI: 1.09-2.95). CONCLUSIONS: PTSD is a risk factor for both ischemic and hemorrhagic stroke and is associated with recurrent strokes. Dust exposure on 9/11 is a possible risk factor for ischemic stroke but not for hemorrhagic stroke, and was not associated with recurrent strokes. Our findings warrant additional research on stroke-morbidity and mortality associated with 9/11-related PTSD and dust exposure.

Comparison of prevalence and exposure-disease associations using self-report and hospitalization data among enrollees of the world trade center health registry.

BACKGROUND: Although many studies have investigated agreement between survey and hospitalization data for disease prevalence, it is unknown whether exposure-chronic disease associations vary based on data collection method. We investigated agreement between self-report and administrative data for the following: 1) disease prevalence, and 2) the accuracy of self-reported hospitalization in the last 12 months, and 3) the association of seven chronic diseases (rheumatoid arthritis, hypertension, heart attack, stroke, asthma, diabetes, hyperlipidemia) with four measures of 9/11 exposure. METHODS: Enrollees of the World Trade Center Health Registry who resided in New York State were included (N = 18,206). Hospitalization data for chronic diseases were obtained from the New York State Planning and Research Cooperative System (SPARCS). Prevalence for each disease and concordance measures (kappa, sensitivity, specificity, positive agreement, and negative agreement) were calculated. In addition, the associations of the seven chronic diseases with the four measures of exposure were evaluated using logistic regression. RESULTS: Self-report disease prevalence ranged from moderately high (40.5% for hyperlipidemia) to low (3.8% for heart attack). Self-report prevalence was at least twice that obtained from administrative data for all seven chronic diseases. Kappa ranged from 0.35 (stroke) to 0.04 (rheumatoid arthritis). Self-reported hospitalizations within the last 12 months showed little overlap with actual hospitalization data. Agreement for exposure-disease associations was good over the twenty-eight exposure-disease pairs studied. CONCLUSIONS: Agreement was good for exposure-disease associations, modest for disease prevalence, and poor for self-reported hospitalizations. Neither self-report nor administrative data can be treated as the "gold standard." Which source to use depends on the availability and context of data, and the disease under study.

Hospitalizations among World Trade Center Health Registry Enrollees Who Were under 18 Years of Age on 9/11, 2001-2016.

Much of the literature on hospitalizations post-September 11, 2001 (9/11) focuses on adults but little is known about post-9/11 hospitalizations among children. Data for World Trade Center Health Registry enrollees who were under 18-years old on 9/11 were linked to New York State hospitalization data to identify hospitalizations from enrollment (2003-2004) to December 31, 2016. Logistic regression was used to analyze factors associated with hospitalization. Of the 3151 enrollees under age 18 on 9/11, 243 (7.7%) had at least one 9/11-related physical health hospitalization and 279 (8.9%) had at least one 9/11-related mental health hospitalization. Individuals of non-White race, those living in New York City Housing Authority housing, those exposed to the dust cloud on 9/11, and those with probable 9/11-related PTSD symptoms were more likely to be hospitalized for a 9/11-related physical health condition. Older age and having probable 9/11-related PTSD symptoms at baseline were associated with being hospitalized for a 9/11-related mental health condition. Dust cloud exposure on 9/11 and PTSD symptoms were associated with hospitalizations among those exposed to 9/11 as children. Racial minorities and children living in public housing were at greater risk of hospitalization. Continued monitoring of this population and understanding the interplay of socioeconomic factors and disaster exposure will be important to understanding the long-term effects of 9/11.

Post-9/11 Mental Health Comorbidity Predicts Self-Reported Confusion or Memory Loss in World Trade Center Health Registry Enrollees.

Numerous studies report elevated levels of chronic mental health conditions in those exposed to the World Trade Center attacks of 11 September 2001 (9/11), but few studies have examined the incidence of confusion or memory loss (CML) or its association with mental health in 9/11 attack survivors. We investigated the incidence of CML and its association with the number of post-9/11 mental health conditions (PTSD, depression, and anxiety) in 10,766 World Trade Center Health Registry (Registry) enrollees aged 35-64 at the time of the wave 4 survey (2015-2016) that completed all four-wave surveys and met the study inclusion criteria. We employed log-binomial regression to evaluate the associations between CML and the number of mental health conditions. A total of 20.2% of enrollees in the sample reported CML, and there was a dose-response relationship between CML and the number of mental health conditions (one condition: RR = 1.85, 95% CI (1.65, 2.09); two conditions: RR = 2.13, 95% CI (1.85, 2.45); three conditions: RR = 2.51, 95% CI (2.17, 2.91)). Survivors may be experiencing confusion or memory loss partly due to the mental health consequences of the 9/11 attacks. Clinicians treating patients with mental health conditions should be aware of potential cognitive impairment.

Injury Severity and Psychological Distress Sustained in the Aftermath of the Attacks of 11 September 2001 Predict Somatic Symptoms in World Trade Center Health Registry Enrollees Sixteen Years Later.

The World Trade Center attacks of 11 September 2001 (9/11) have been associated with the subsequent development of chronic diseases. Few studies have investigated the burden of somatic symptoms on attack victims, or the association of such symptoms with exposure to the 9/11 attacks. World Trade Center Health Registry (Registry) enrollees who were present south of Chambers Street during or immediately after the 9/11 attacks and who provided consistent answers regarding injury sustained on 9/11 were followed prospectively for up to 16 years post-9/11/01. We employed linear regression to evaluate the associations between injury severity, psychological distress and somatic symptoms in 2322 persons who completed all four Registry surveys and a subsequent Health and Quality of Life survey. Twenty-one percent of subjects had a "very high" burden of somatic symptoms, greater than in populations not exposed to a disaster. Somatic symptoms exhibited a dose-response association separately with injury severity and psychological distress trajectories. Victims of the 9/11 attacks suffer from a substantial burden of somatic symptoms which are associated with physical and psychological consequences of exposure to the attacks. Physical and mental health professionals need to work together when treating those exposed to complex disasters such as 9/11.

Association Between Socioeconomic Status and Asthma-Related Emergency Department Visits Among World Trade Center Rescue and Recovery Workers and Survivors.

Importance: Although the association between poor economic or social standing and health is well established, few studies have attempted to examine the mediational pathways that produce adverse outcomes in disadvantaged populations. Objective: To determine whether barriers to care mediate the association between socioeconomic status (SES) and asthma-related emergency department (ED) visits. Design, Setting, and Participants: This cohort study used data from the World Trade Center Health Registry, which comprises rescue and recovery workers and community members who worked, lived, studied or were otherwise present in downtown Manhattan, New York, during or immediately after the September 11, 2001, disaster. Data were matched to an administrative database of ED visits. Those who experienced an asthma-related ED visit and those who did not were compared in bivariate analysis. A mediation analysis was conducted to determine the role of barriers to care in the association between number of ED visits and SES. Exposures: Education, income, and race/ethnicity, which were collected at first survey in 2003 to 2004. Main Outcomes and Measures: Asthma-related ED visits that occurred after survey responses regarding barriers to care were collected (2006-2007) but before 2016, the latest date that data were available. Results: The analytic sample included 30 452 enrollees (18 585 [61%] male; median [interquartile range] age, 42.0 [35.0-50.0] years; 20 180 [66%] white, 3834 [13%] African American, and 3961 [13%] Hispanic or Latino [any race]). Approximately half (49%) had less than a bachelor's degree, and 15% had an annual income less than $35 000. Those of lower SES were more likely to experience an asthma-related ED visit. Although number of barriers to care mediated this association, they explained only a small percentage of the overall health disparity (ranging from 3.0% [95% CI, 2.3%-3.9%]) of the differences between African American and white individuals to 9.8% [95% CI, 7.7%-11.9%]) comparing those with less than a high school diploma to those with at least a bachelor's degree. However, the association varied by specific barrier to care. Lack of money, insurance, and transportation mediated up to 11.8% (95% CI, 8.1%-15.9%), 12.5% (95% CI, 8.5%-17.4%), and 4.3% (95% CI, 1.7%-8.4%), respectively, of the association between SES and number of ED visits. Lack of childcare, not knowing where to go for care, and inability to find a health care professional mediated a smaller or no percentage of the association. Conclusions and Relevance: The identification of vulnerable subpopulations is an important goal to reduce the burden of asthma-related hospital care. More research is needed to fully understand all of the pathways that lead disaster survivors of lower SES to disproportionately experience ED visits due to asthma.

An Assessment of Long-Term Physical and Emotional Quality of Life of Persons Injured on 9/11/2001.

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.

9/11 Residential Exposures: The Impact of World Trade Center Dust on Respiratory Outcomes of Lower Manhattan Residents.

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.

Re-experiencing 9/11-Related PTSD Symptoms Following Exposure to Hurricane Sandy.

BACKGROUND: Understanding Pre-Existing Posttraumatic Stress Disorder (PTSD) symptoms and risk of PTSD following Hurricane Sandy (Sandy) has important implications for PTSD screening of persons exposed to multiple traumas. This study assessed the association between Sandy exposure and a subset of PTSD symptoms related to re-experiencing trauma from the events of the September 11, 2001 (9/11). METHODS: We studied 4,220 respondents from a random 8,870 person sample of adult World Trade Center Health Registry enrollees who completed a post-Sandy survey between March 28 and November 7, 2013. The symptom cluster of re-experiencing 9/11 was defined using 3 out of 5 questions in the intrusion domain of the PTSD Checklist. Multivariable logistic regression, adjusting for socio-demographics, social support and any post-9/11 life threatening events prior to Sandy, was performed separately in those symptomatic and non-symptomatic of re-experiencing 9/11 prior to Sandy. RESULTS: A total of 688 enrollees (16.3%) reported re-experiencing 9/11 symptoms after Sandy (58.8% in those symptomatic prior to Sandy, and 8.7% in those non-symptomatic). A significant association between Sandy exposure and re-experiencing 9/11 was observed only among those non symptomatic prior to Sandy (adjusted odds ratio (AOR)=1.7, 95% confidence interval=1.2-2.3 for moderate Sandy exposure; AOR=2.8, 2.0-4.0 for high Sandy exposure). CONCLUSIONS: Individuals with a history of trauma should be considered for early screening and counseling for mental health after a subsequent traumatic event, regardless of PTSD status, especially in 9/11 exposed populations.

Risk of Stroke Among Survivors of the September 11, 2001, World Trade Center Disaster.

OBJECTIVE: The aim of this study was to investigate the association between 9/11-related posttraumatic stress disorder (PTSD), dust cloud exposure, and subsequent development of stroke among 42,527 enrollees in the World Trade Center (WTC) Health Registry. METHODS: Using four waves of longitudinal data from the WTC Health Registry surveys, we employed Cox proportional hazards regression models to assess the associations. RESULTS: Incidence of stroke was higher among those with PTSD or intense dust cloud exposure than those without, and it was even higher for those who had experienced both. In fully adjusted models, participants with PTSD had an increased risk of developing stroke [adjusted hazards ratio (AHR) 1.69, 95% confidence interval (95% CI) 1.42 to 2.02], as did those with intense dust exposure (AHR 1.29, 95% CI 1.09 to 1.53). CONCLUSION: We found that individuals with 9/11-related PTSD and/or intense dust exposure may have an increased risk of developing stroke.

Injury, intense dust exposure, and chronic disease among survivors of the World Trade Center terrorist attacks of September 11, 2001.

BACKGROUND: The World Trade Center attack of September 11, 2001 in New York City (9/11) exposed thousands of people to intense concentrations of hazardous materials that have resulted in reports of increased levels of asthma, heart disease, diabetes, and other chronic diseases along with psychological illnesses such as post-traumatic stress disorder (PTSD). Few studies have discriminated between health consequences of immediate (short-term or acute) intense exposures versus chronic residential or workplace exposures. METHODS: We used proportional hazards methods to determine adjusted hazard ratios (AHRs) for associations between several components of acute exposures (e.g., injury, immersion in the dust cloud) and four chronic disease outcomes: asthma, other non-neoplastic lung diseases, cardiovascular disease, and diabetes, in 8701 persons free of those conditions prior to exposure and who were physically present during or immediately after the World Trade Center attacks. Participants were followed prospectively up to 11 years post-9/11. RESULTS: Heart disease exhibited a dose-response association with sustaining injury (1 injury type: AHR =2.0, 95% CI (Confidence Interval) 1.1-3.6; 2 injury types: AHR = 3.1, 95% CI 1.2-7.9; 3 or more injury types: AHR = 6.8, 95% CI 2.0-22.6), while asthma and other lung diseases were both significantly associated with dust cloud exposure (AHR = 1.3, 95% CI 1.0-1.6). Diabetes was not associated with any of the predictors assessed in this study. CONCLUSION: In this study we demonstrated that the acute exposures of injury and dust cloud that were sustained on 9/11/2001 had significant associations with later heart and respiratory diseases. Continued monitoring of 9/11 exposed persons' health by medical providers is warranted for the foreseeable future.

The effectiveness of a monetary incentive offer on survey response rates and response completeness in a longitudinal study.

BACKGROUND: Achieving adequate response rates is an ongoing challenge for longitudinal studies. The World Trade Center Health Registry is a longitudinal health study that periodically surveys a cohort of ~71,000 people exposed to the 9/11 terrorist attacks in New York City. Since Wave 1, the Registry has conducted three follow-up surveys (Waves 2-4) every 3-4 years and utilized various strategies to increase survey participation. A promised monetary incentive was offered for the first time to survey non-respondents in the recent Wave 4 survey, conducted 13-14 years after 9/11. METHODS: We evaluated the effectiveness of a monetary incentive in improving the response rate five months after survey launch, and assessed whether or not response completeness was compromised due to incentive use. The study compared the likelihood of returning a survey for those who received an incentive offer to those who did not, using logistic regression models. Among those who returned surveys, we also examined whether those receiving an incentive notification had higher rate of response completeness than those who did not, using negative binomial regression models and logistic regression models. RESULTS: We found that a $10 monetary incentive offer was effective in increasing Wave 4 response rates. Specifically, the $10 incentive offer was useful in encouraging initially reluctant participants to respond to the survey. The likelihood of returning a survey increased by 30% for those who received an incentive offer (AOR = 1.3, 95% CI: 1.1, 1.4), and the incentive increased the number of returned surveys by 18%. Moreover, our results did not reveal any significant differences on response completeness between those who received an incentive offer and those who did not. CONCLUSIONS: In the face of the growing challenge of maintaining a high response rate for the World Trade Center Health Registry follow-up surveys, this study showed the value of offering a monetary incentive as an additional refusal conversion strategy. Our findings also suggest that an incentive offer could be particularly useful near the end of data collection period when an immediate boost in response rate is needed.