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CDC Telebriefing Transcript

MMWR Examines Health Effects Related to World Trade Center Terrorist Attacks

Dr. Thomas Matte
CDC Physician/Environmental Epidemiologist

Dr. Joanne Fagan
Epidemiologist/Consultant New York Academy of Medicine

Dr. Wayne Giles
CDC Physician/Cardiovascular Epidemiologist and
Occupational Health Expert

September 5, 2002

CDC MODERATOR: [In progress] -- vascular epidemiologist with CDC's Chronic Disease Center, and he's going to discuss findings on the psychological and emotional effects of the September 11th attacks.

And then finally we'll hear from Dr. Elena Page--that's Elena, E-l-e-n-a, Page, P-a-g-e. She's an Occupational Health Expert with NIOSH, the National Institution for Occupational Safety and Health, and she'll be discussing a notice to readers on Guidelines for Workers at Anthrax Contaminated Sites.

Following the three speakers' comments, we will open it up for questions.

And now let's get started with Dr. Matte.

DR. MATTE: Good afternoon.

Asthma is a common chronic disease that could be made worse by environmental factors and psychological factors. The report being released today describes asthma symptoms reported in a telephone survey of a sample of adult Manhattan residents. The survey, conducted by investigators at the New York Academy of Medicine, took place 5 to 9 weeks after the September 11th attacks on the World Trade Center.

The researchers conducted the survey mainly to assess the psychological impact of the attacks, and these have been reported in previous publications.

The asthma questions analyzed in the study were included in the survey to see how the attacks might have affected persons with asthma. Although the study has some important limitations, the results suggest that both environmental and psychological consequences of the attacks were related to an increase in symptoms reported last fall by some Manhattan adults with asthma.

1,008 people participated in the survey. 13 percent of those participants said they had been told previously by a doctor that they had asthma. Of the participants with asthma, 27 percent reported more severe asthma in the weeks between September 11th and the time they were interviewed than in the 4 weeks before September 11th.

I should note here that asthma attacks usually increase in the fall, so some increase in asthma severity was not unexpected. However, in this survey, asthmatics who reported difficulty breathing because of smoke and debris during the attacks were more likely to report that their asthma was more severe in the weeks since September 11th than prior to the attacks.

Also, people with asthma who reported psychological distress associated with the September 11th attacks, including a panic attack, depression or post traumatic stress disorder during the past month, these people were also more likely to report an increase in asthma severity.

Having two or more life stressors in the 12 months prior to September 11th was also strongly associated with reported worsening of asthma. Now, experiencing prior life stressors like the death of a close family member, a serious illness of injury, or a change in marital status, such an experience is a risk factor for developing post traumatic stress disorder.

These findings are consistent with what we know about asthma. Asthma attacks can be triggered by exposure to respiratory irritants such as particulate matter and other components of smoke. They also can be triggered by psychological stress.

In addition, post traumatic stress disorder has been associated with increases in physical illnesses and complaints including respiratory symptoms.

As I mentioned, the study does have some important limitations. Please keep these in mind. For example, it relied on self report of symptoms and exposure. In addition the study had a cross-sectional design. This means asthma symptoms, exposures, psychological distress, these were all measured at the same point in time. Finally, remember asthma usually worsens in the fall.

Because of these limitations the study can't prove or quantify a causal link of the September 11th attacks to worsening asthma. But despite these limitations, the survey results suggest that both environmental and psychological impacts of the September 11th attacks contributed to an increase in symptoms that some asthmatics in Manhattan experienced last fall.

Asthma patients and their doctors should be aware that both the environmental and psychological effects of disasters might worsen their asthma symptoms.

Thank you, and Dr. Fagan and I will be happy to answer questions during that part of the program.

CDC MODERATOR: Thank you, Dr. Matte.

And now we're going to hear from Dr. Wayne Giles.

DR. GILES: Good afternoon, everyone.

In order to measure the psychological and emotional effects of the September 11th attacks on the United States, the States of New York, New Jersey and Connecticut, added questions about terrorism to the Behavioral Risk Factor Surveillance system, and they started asking these questions on October 11th and this continued until December 31st.

The BRFS is a monthly telephone survey that's conducted by CDC's Behavioral Surveillance Branch, along with state health departments. The special bioterrorism module included a total of 17 questions, which asked respondents about whether they were victims of the terrorist attacks, whether they attended a memorial or funeral service after the attacks, whether they were employed or missed work after the attacks, if they increased their consumption of tobacco or alcohol following the attacks, or whether they watched more media coverage following the attack. And a total of 3,512 people across these three states participated in the survey.

What we found in the survey was that 75 percent of the participants across these three states responded that they reported having problems after the attack. 48 percent reported experiencing increase anger. Men and women of all ages, all education levels and race/ethnic groups reported sizable impact on their lives. Approximately 12 percent of the respondents reported receiving help for their problems, and most turned to family members and friends or neighbors.

Approximately 50 percent of those who responded said they participated in a religious or community memorial service after the attacks, and 13 percent attended a funeral or memorial service for a family, friend or acquaintance.

One of the nice parts about this study is the fact that not only do we look at the emotional and psychological impact, but we also looked at adverse health behaviors. And we found that 21 percent smokers reported an increase in smoking after their attack. 1.4 percent of nonsmokers reported that they began smoking after the attack. And 3.2 percent of alcohol drinkers said that they increased their consumption of alcohol after the attack.

Women who smoked were more likely to report an increase in smoking than men, and men were more likely than women to report an increase in alcohol consumption. More than 80 percent of the respondents reported watching more media coverage or television or looking through Internet after the attacks. 3 percent of the respondents reported that they were a victim of attacks. Approximately 7 percent reported that they had a relative who was a victim of the attacks, and 14 percent had a friend who was a victim.

The findings in this report underscore the need for health professionals to consider the emotional and psychological well being of Americans after traumatic events and to integrate into existing disaster preparedness plans programs that address the emotional and psychological health of those affected. One of the things that we don't want to occur is we don't want people adopting adverse health behaviors after these traumatic events. And so studies such as this are important because they can document what's happening, but also allow public health professionals to develop programs to alleviate it so that people will not--will not undertake or initiate adverse health behaviors.

CDC MODERATOR: Thank you, Dr. Giles.

And now we're going to hear from Dr. Elena Page.

DR. PAGE: All right. Thank you.

Since early October 2001, as you all know, CDC's been investigating multiple cases of anthrax related to deliberately contaminated letters sent through the U.S. Postal Service. Decontamination activities have been initiated in contaminated buildings and offices along the paths of the implicated letters and downstream from contaminated mail processing centers.

Federal guidelines and Occupational Safety and Health Administration regulations for hazardous waste operations and emergency response, or HAZWOPER, may be pertinent to chemical exposures and the use of personal protective equipment and clothing, but may not be sufficient for protecting these workers against anthrax. This current MMWR recommends new CDC guidelines that go beyond HAZWOPER requirements for a medical program.

These additional guidelines will provide the highest level of protection for workers who enter contaminated buildings to make them safe for others to enter and occupy. Because the exposure of potential to B. anthraces or Bacillus anthraces spores continues as long as the decontamination work continues, and because prolonged antibiotic use is not without risk, these workers should be offered the anthrax vaccine. Because the risk of inhalational anthrax continue beyond the last exposure to anthrax spores, medical follow up should be continued beyond the date of last exposure, i.e., for a longer period than HAZWOPER requires.

The transient nature of the work and the high mobility of the work force will require special arrangements for the medical follow up of workers after they leave the work site.

CDC MODERATOR: Thank you, Dr. Page.

And now I believe we're ready to open it up for questions.

AT&T OPERATOR: And once again, ladies and gentlemen, if you do have a question at this time, please press the 1 on your touchtone phone.

Our first question is from the line of Shankar Venantam (ph) with the Washington Post. Please go ahead.

QUESTION: Dr. Giles, you said that results like this could help practitioners attend to the psychological needs of victims after a terrorist attack. What exactly should they do? What has been documented to work and what has been documented to be effective in preventing adverse health behaviors or psychological problems?

DR. GILES: An excellent question. I think there are several things that have been proven to be effective. There have been a number of studies that have looked at this, and I think one of the--one of the important areas is physical activity. There's double studies, for example, that have shown that moderate levels of physical activity can be very effective in terms of helping people to cope with stress and to improve psychological well being. So clearly physical activity is one thing that people can do, particularly moderate levels of physical activity.

QUESTION: Do you have any sense on sort of the debriefing sessions, the counseling sessions that are offered immediately after tragedies like this, whether they're effective or not?

DR. GILES: I think that's a good question, and I think that's something that we'll have to--that wasn't part of this initial study that we did here, but that's something that we will have to look at in further analysis.

CDC MODERATOR: Thank you. Next question.

AT&T OPERATOR: And that's from the line of Megal Burks with Reuters Health. Please go ahead.

QUESTION: Hi. Yeah, I'm sorry. I just missed Dr. Fagan's first name and affiliation.

DR. FAGAN: It's Joanne, and I'm a consultant with the New York Academy of Medicine.

QUESTION: And Dr. Matte, is he based in New York City or Atlanta?

DR. MATTE: In New York City.

QUESTION: Thank you.

CDC MODERATOR: Thank you. Next question.

AT&T OPERATOR: And that's from the line of Andrew Matte with the Toronto Town Crier. Please go ahead.

QUESTION: Yeah. I wanted to expand just a little bit in terms of the psychological effects of just members of the public at large after the attacks. I gather your study included representatives of people who lived in and around New York City. Do you have any information in regards to members of the public who obviously witnessed the attacks and followed the news of the attacks in the following weeks and months after the attacks, and obviously people who had relatives and close friends who were victims of the attacks, were, you know, affected and exhibited signs of post traumatic stress disorder and that kind of thing?

But what about people who live outside of the city and outside of the U.S. and around the world? I'm sure there are people who need counseling as well.

DR. GILES: I think one of the nice parts about this study is that, you know, when a disaster such as what happened on September 11th occurs, we tend to target our resources towards the area that's been immediately affected, and one of the things that this study showed was that in fact the number of people who were affected was actually broader than just, you know, sort of Ground Zero or the Manhattan area, but included the entire states of Connecticut, New Jersey and New York.

We do need to do additional analyses though to look at what's happened across the United States, and I think that's one of the nice things about the Behavioral Risk Factor Surveillance System, BRFS, is that it's very flexible and allows us to ask questions so that we can respond to crises that occur like what occurred on September 11th.

QUESTION: So it's safe to assume then that your study included regular folks as opposed to people with a direct affiliation to the attacks themselves?

DR. GILES: Oh, yes. The study itself surveyed all residents of New Jersey, New York and Connecticut from October 11th, one month after the attacks, through December 31st.

QUESTION: One more quick follow up question. It was interesting from your answer to the last question about how people could seek counseling and adjust their behavior to combat the symptoms. Can you tell me a little bit more specifically about the symptoms itself of post traumatic stress disorder, how that manifests itself and what people go through either mentally or physically?

DR. GILES: I want to clarify that we didn't look specifically at post traumatic stress disorder which has a specific diagnosis criteria, so we didn't look at that. What we looked at were, you know, were people having problems with increased anger, nervousness, worry, sleep problems, helplessness, loss of control over external events. Those were the things that we looked at, and those were what we assessed in the article.

CDC MODERATOR: Thank you. Next question please.

AT&T OPERATOR: That's from Steve Mitchell, United Press International. Please go ahead.

QUESTION: My question is for Dr. Page in terms of these new anthrax protection recommendations. You're saying that none of the decontamination workers have actually contracted anthrax, but the current guidelines may not be sufficient for protecting them. So can you sort of expand on where there might be gaps and exactly how you would improve those other than the vaccine?

DR. PAGE: Well, obviously, all the workers are wearing personal protective equipment, and that's their sort of first line of defense, but it's not perfect. And then there ware other factors that are like the way the workers wear them, or they can have a breach. You know, the situations are not controlled. Something could happen to breach their PPE. And so they may still have exposure to spores. Therefore, in addition to the antibiotic prophylaxis that has already been recommended, we're recommending that they be vaccinated because this work could be ongoing for a very long period of time, and if they take the antibiotics for a very long period of time, they suffer the risk of usually mild but occasionally severe side effects.

CDC MODERATOR: Thank you. Next question please.

AT&T OPERATOR: And that's from the line of Edward Edelson with Health Scout. Please go ahead.

QUESTION: This is direct to both Drs. Fagan and Matte. It's a two-prong question. First, what are the practical implications of this finding for people with asthma and physicians who treat people with asthma?

And second, you are talking in terms of results of a disaster. How disastrous does an occurrence have to be to invoke this sort of reaction? Does it start as something like an automobile accident and so on?

DR. MATTE: This is Dr. Matte. I think the practical implications for people with asthma and their clinicians are first of all, following a disaster it's particularly important to make sure people are doing the things that we know are helpful to controlling asthma, that they're taking the right medications, that they're doing the things that they can do to avoid triggers that they know trigger their asthma.

This also suggests that some people who are presenting with increased asthma that could be in part due to psychological consequences of the disaster, making sure that clinicians are alert to that possibility, and if that appears to be something that is going on, they get the appropriate referrals and connections to services for those kinds of problems.

There's always, you know, difficult with an event like this, of knowing how generalizable it is. I think there is past data that indicates that events that are serious enough to produce psychological consequences such as post traumatic stress disorder can cause physical complaints in people, including respiratory symptoms and more people with asthma seeking health care. So if there is an event that's sufficient enough to produce the psychological consequences, it would be reasonable to think it could affect people with asthma.

As far as the environmental consequences are concerned, there have been other studies of populations near, for example, large structural fires or brush fires or forest fires near urban areas that showed that people with asthma can be affected by those kinds of events.

I really don't think a comparison with a discrete event like an automobile accident--it's very difficult to make--possibly for the person who's involved, if they had asthma, it could be very significant for them, but in terms of a public health impact, it's quite a different situation.

QUESTION: Dr. Fagan, has an attempt been made to continue to follow up what's happening to people with asthma and other conditions in the New York area?

DR. FAGAN: Well, there are--this study was a population that we are not contacting again. We didn't get personal identifiers for this population. We have conducted two other surveys, random surveys, in similar populations, expanding out to some of the suburbs, and some of the other parts of New York. However, there are other things that are going on in New York City that are following up with populations that are programs that were already in place, and because we expect that there would be more problems, you know, people in the Department of Health and various agencies throughout the city are working on this.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: And that's from the line of Anita Manning with USA Today. Please go ahead.

QUESTION: Hi, I'm sorry. I had you on mute. I just had to cut out for a moment so I hope this question hasn't already been answered. But it's about the asthma report. And you mentioned that severe asthma always increases in the fall, and I'm wondering if you can say by how much, so we can get a sense of whether a 27 percent increase among people who have asthma, how much greater that is than what you might have expected anyway.

DR. MATTE: We don't have data that's directly comparable to this to say whether 27 percent is more or less than expected. But I'll try to answer the question in two ways. One is that we know hospitalizations for asthma and emergency room visits for asthma increase quite substantially sometime between around August and the beginning of October. The exact timing of the seasonal increase varies from year to year, and that can be quite a significant increase, more than even a doubling. But that's different from asking individual people with asthma whether their asthma got worse or not.

Maybe I'll let Dr. Fagan highlight some of the results that sort of compare people who had one of these psychological risk factors to people who didn't to show how much of a difference there was in their likelihood of reporting that asthma got worse for them.

DR. FAGAN: For people who said that they had at least two or more life stressors in the 12 months prior, 23 percent of the people said that they had worse--sorry--for people with life stressors, if they had zero life stressors, it was only about 21 percent of these people had worsening of their asthma. And if they had two or more, it was as high as almost 47 percent. For people who said that they experienced a peri-event panic attack, people who experienced that were--47 percent of those people were more likely to have a worsening of asthma compared to 20 percent, 20 percent, the people who said no, they did not have a peri-panic attack, only 20 percent of those had worsening of the symptoms.

For depression, it was 47 percent versus 23 percent, and for post traumatic stress syndrome it was 53 percent versus 24 percent.

DR. MATTE: So the way I would interpret that is to say there was quite a substantial increase in the chance that someone who had a--there was more than a doubling among people who had a psychological impact of the attack, that they would experience their asthma as being worse. And I wouldn't want to interpret it much more than that. I think that's really one of the limitations of the study and one of the things that I think is going to complicate other studies that are ongoing, looking at the impact of this event on people with asthma, that asthma has a very strong seasonal component that happens to coincide around the time that this tragedy took place.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: That's from Tom Watkins, CNN. Please go ahead.

QUESTION: Tom Watkins. You say 27 percent increase in asthma severity, and that normally during a typical fall there's an increase. Do you know by how much in the fall it increases? So in other words, if it goes up 50 percent, one could argue that actually the thing was associated with a decrease in asthma.

DR. MATTE: Just for clarification, what the study found was not a 27 percent increase in asthma severity. It found that 27 percent of people with asthma, when they were interviewed 5 to 9 weeks after the attack, said their asthma was more severe than it had been prior to September 11th. Okay?

Now, a problem that we have is that we don't have similar surveys that have been done in similar places at that exact time of the year to say how many other asthmatics would report that their asthma was more severe.

QUESTION: So in other words, you don't really know--we can't really say that there's an increase--that this was--there's a causal deal here, right?

DR. MATTE: Right. As I said, because of the limitations of the study we can't say exactly how much the World Trade Center attack contributed to an increase in asthma severity.

QUESTION: Of at all.

DR. MATTE: What we can say though is that we know many people last fall--and other surveys have shown this--were experiencing respiratory symptoms. What we can say is that people with asthma, if they had a psychological impact of the attack or if they had the experience of difficulty breathing from smoke during the attack, they were more likely to report that their asthma had gotten worse. And so it suggests, and it's consistent with other information about asthma, that for some people, their experience of worsening symptoms, among those 27 percent who felt their asthma had been--was worse, that it was related to these psychological and environmental consequences of the attack.

QUESTION: Okay, thank you.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: That's from Klaus Meier with the Inside Washington Publishers. Please go ahead.

QUESTION: Yeah, I have a question for Dr. Page. Regarding your anthrax guidelines that you proposed, do you think that will be sufficient, or do you think that OSHA standard needs to updated?

DR. PAGE: I think the guidelines that we have proposed will be sufficient. We put them in place specifically to give the highest level of protection to these workers. They are not an OSHA guideline, however. These go beyond the OSHA HAZWOPER standard.

QUESTION: So but you don't feel that OSHA, in addition to your guidelines, should also update its own standard?

DR. PAGE: No, not specifically for anthrax. There are so many things, and the HAZWOPER standard provides sort of a generic template that you can use to model for different situations, and I think that's an appropriate thing. It would be impossible to sort of plan, for OSHA to plan for every possible eventuality, but our guideline should definitely provide the highest level of protection for the decontamination workers.

QUESTION: And Dr. Page, could you state your position at NIOSH one more time, please?

DR. PAGE: Yes. I'm a supervisory medical officer. I'm a physician, an epidemiologist.

QUESTION: Okay, thank you.

DR. PAGE: Sure.

CDC MODERATOR: Thank you. Next question, please.

QUESTION: Yes. For Dr. Matte, very quickly. I'd like to know in terms of worsening of asthma, does this mean that people reported being hospitalized or was it just a matter of saying, "I had a worsening of symptoms, that my respiration was worse?" Can you explain what you meant by that, the increase in the severity of symptoms.

DR. FAGAN: Okay. This is Dr. Fagan. What we asked them is to try to say how their asthma was. And they either could have had no symptoms, mild, moderate or severe. And for people whose asthma got worse, it went from being no symptoms to mild, to moderate and severe.

Now, we did ask them about visits to the emergency room, hospitalization for asthma, and also unscheduled visits to physicians. And the group that did say that they had more--a worsening of asthma, compared to the group that did not have a worsening of asthma, were more likely to have unscheduled asthma--unscheduled visits to a physician, were more likely to visit an emergency room for asthma. And for hospitalizations, there were only two hospitalizations, so we really can't way much on that.

For the unscheduled visits, that was statistically significant. It was 28 percent versus 5 percent. It was not statistically significant for the emergency room visits, but it did go in the right direction, the ones who had complained of a worsening of asthma did have more emergency room visits for asthma than those that did not.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: We have a follow up from Shankar Venantam. Please go ahead.

QUESTION: Hi, a follow up for Dr. Giles once again. Would you have any idea what the numbers are at the current time? This is--the numbers you are giving us, obviously, are 8, 9 months old at this point. Has there been any follow-up work that's been done, or would you be able to estimate from these numbers, you know, there's probably going to be a decline in the numbers 9 months down the road, but would you know how much of a decline?

And the second part of the question is you had mentioned exercise as one thing that people could do after disasters to reduce the psychological impact of trauma. Is there any other specific intervention that comes to mind, doctor?

DR. GILES: I think there are a couple of things. One, on the first part, is you're right, it has been 8 or 9 months since we finished the survey. And we are going to have to go back and talk with the people in the states of Connecticut, New Jersey and New York, and talk with them about repeating the survey, because I do think that is something that would be very valuable, and we will talk with them about that.

I think there are a number of--I think another important issue is just making sure that people have an opportunity to discuss these issues, to discuss how they're feeling, and providing people with opportunities to do that is something that counselors and public health practitioners can help to facilitate.

QUESTION: Is there a way you can hazard how much the numbers might look like now?

DR. GILES: I would really be reluctant to do that without the actual data. And so I think really what we need to do is talk with the states and go back in the field and actually collect the data.

QUESTION: And anything else besides exercise? Is that what you meant when you talked about the psychological counseling?

DR. GILES: What I mean in terms of the--what I meant for the psychological counseling, was, you know, giving people an opportunity to discuss what's going on and discuss their feelings. What I was talking about in terms of physical activity was that was a lifestyle behavior that one could engage in that helps to relieve stress that's effective as opposed to doing the unhealthy behavior such as increased alcohol and tobacco consumption. That was an example.

QUESTION: Okay, thank you.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: We have a follow-up from Steve Mitchell. Please go ahead.

QUESTION: My question is for Dr. Giles. I just wanted to get a sense of whether the findings you're talking about today are--were unexpected or whether this is--this kind of change after a traumatic event is sort of already known, or how this sort of fits in in overall context?

DR. GILES: I would say sort of do that one a two pronged. I think we did know that there was going to be an impact. I think clearly the fact that the impact affected the entire state is surprising.

I think the other thing that was surprising was the fact that 21 percent of smokers said they increased their smoking, the fact that 3 percent of people who drank said they increased the alcohol consumption. We were surprised to see the changes in terms of adverse behaviors after the events.

QUESTION: Okay, thanks.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: And that's from Deitra Henderson with the Denver Post. Please go ahead.

QUESTION: This question is for Dr. Giles. Because so many people who were surveyed tuned in to post 9-11 coverage in various media--I think the percentage you mentioned was 80 percent--was there any effort the look at the impact or reliving the trauma? And does that cumulative impact of reliving the attacks have a role in the increased stress and anger that you've seen?

DR. GILES: That's an excellent question, and I think that's something that we will have to look at in future analyses, and we'll do that. We didn't do that in this report.

CDC MODERATOR: Thank you. Next question, please.

AT&T OPERATOR: Ms. Hunter, no further questions.

CDC MODERATOR: Great. Well, that wraps it up. Just a reminder, the West Nile virus telebriefing, as I mentioned earlier, that had been scheduled for 2:00 p.m. with Dr. Lyle Peterson will now happen at 6:00 p.m. Eastern time today. The call-in number will be the same. And if any reporters need additional information about the MMWR articles discussed during this telebriefing or anything else, please feel free to contact CDC's press office at 404-639-3286. And a transcript of the telebriefing will be available on the Media Relations website later this afternoon.

So thank you all for joining us and that wraps up this telebriefing.

AT&T OPERATOR: Ladies and gentlemen, that does conclude your conference for today. Thank you for your participation, and you may now disconnect.

[End of telebriefing.]

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