ATLANTA—A substantial proportion of adult Manhattanites with asthma reported an increase in symptoms in the weeks after the September 11, 2001, terrorist attacks, according to a CDC report of a New York Academy of Medicine study.[1] While the autumn increase had been expected, the investigators found worsened symptoms were more commonly reported by asthmatic patients who had suffered marked psychological distress before or after the attacks or had difficulty breathing during the attacks because of smoke and debris.

The researchers spotted the increase when they randomly surveyed 1,008 adult Manhattanites; of those with asthma, 27% indicated that they had more severe symptoms after September 11. The survey was part of a larger study focusing on the psychologic effects of the terrorist attacks. During the two months after the attacks, investigators led by Joanne Fagan, PhD, conducted telephone interviews with Manhattan residents to ask about their physical and mental health; included were questions about the presence or absence of asthma and the severity of asthma symptoms.

Their findings suggest that both exposure to smoke and debris and the resulting psychological stress contributed to the increased symptom severity among the asthma patients surveyed. “Asthma patients and their physicians should be aware that environmental and psychologic effects of disasters like September 11 may worsen asthma symptoms,” advised Dr. Fagan, a consultant for the New York Academy of Medicine in New York City.

RISK FACTORS FOR INCREASED SEVERITY

About 13% (134) of the Manhattanites surveyed reported a physician’s diagnosis of asthma; 17 of these said they had lived close to or were near the World Trade Center when the terrorists struck.

Thirty-four of the asthma patients said that their symptoms had worsened during the next several weeks, becoming moderate to severe (compared to nonexistent or mild during the four weeks before September 11). These patients were more likely to report subsequent unscheduled visits to a health care provider than were asthmatic respondents who did not experience a symptom increase (28% vs. 5%).

In a bivariate analysis, factors that significantly raised the risk of more severe asthma after September 11 included difficulty breathing because of smoke and debris during the attacks, intense panic during or shortly after the attacks, and the presence of two or more life stressors (eg, a death in the family, serious illness or injury, or marital status change) in the 12 months before September 11. Posttraumatic stress disorder related to the attacks and depression in the preceding month increased the risk as well. Further analysis revealed that the two most important risk factors were difficulty breathing because of smoke and debris during the attack and the presence of two or more life stressors in the preceding 12 months. In other words, both environmental exposure and psychological factors played a role.

SURVEY LIMITATIONS

The survey had some important limitations that could have influenced the findings, Dr. Fagan acknowledged. “Unfortunately, our survey took place at a time of year, the fall, when asthma severity usually increases,” she explained, “so the increase we observed may not have only been related to the September 11 attacks.”

Other survey limitations included a lack of objective measures to validate self-reported worsening of asthma, the inability to establish a cause/effect relationship between the attacks and increased asthma severity (due to the cross-sectional nature of the survey), and possible selection bias—that is, people with health problems may have been more or less likely to participate in the survey. “Nevertheless, the statistical relationships we observed were quite strong,” Dr. Fagan said.

September 11: The Respiratory Toll on Firefighters

NEW YORK CITY—Those hit hardest with respiratory repercussions to last September’s World Trade Center attacks were the firefighters who suffered moderate to high levels of exposure to airborne particles during the rescue operations. In our January 2002 issue, we presented a detailed report on the problems—including chronic cough, sore throat, and asthma-like symptoms—that had been detected. Since then, however, more information has become available. For example, recently released study results from David J. Prezant, MD, and colleagues show that 8% of firefighters who were present during the towers’ collapse (defined as high exposure) and 3% of those who were present during the following two days (defined as moderate exposure) developed “World Trade Center cough,” a condition severe enough to require medical leave.[1] In most cases, patients presented complaining of a productive cough with a black to gray sputum. Lung function testing revealed a significant decline in forced vital capacity and forced expiratory volume in one second. High resolution computed tomography was performed on 78 of the 332 firefighters with cough. Of these, air trapping was seen in 51% and bronchial wall thickening in 30%. One surprising finding was that 87% of firefighters with cough reported symptoms of gastroesophageal reflux disease, a condition usually seen in only 25% of patients with chronic cough. In addition, firefighters without the telltale cough also displayed physiological abnormalities. Of those with high exposure, 23% showed airway hyperreactivity, as did 8% of those with moderate exposure. The investigators’ findings demonstrated a correlation between intensity of exposure and risk of airway responsiveness. However, long-term study is necessary to observe whether these symptoms persist over time, possibly indicating reactive airways dysfunction syndrome. —Lisa Pallatroni

Reference 1. Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med. 2002;347:806-815.

—Timothy Begany