Air Today . . . Gone Tomorrow Article|
Reported Increase in
Asthma Severity After the September 11 Attacks on the World Trade Center --- Manhattan,
New York, 2001
Centers for Disease
Control and Prevention, Morbidity and Mortality Weekly Report, September 6, 2002
Asthma is a chronic condition that affects approximately 14 million
persons in the United States and is characterized by airway inflammation, reversible
airway obstruction, and airway hyperresponsiveness to a variety of triggers (1). Both
environmental and psychological factors can trigger asthma exacerbations (2--4), and a
seasonal increase in asthma morbidity occurs in the fall (5). This report summarizes the
results of a telephone survey conducted among Manhattan residents 5--9 weeks following the
September 11, 2001, terrorist attacks on the World Trade Center (WTC) in lower Manhattan
in New York City. The findings indicate that among the 13% of adult respondents with
asthma, 27% reported experiencing more severe asthma symptoms after September 11. Although
a normal seasonal increase in asthma severity was expected, increased severity was
reported more commonly among asthmatics reporting psychological distress associated with
the attacks and/or difficulty breathing because of smoke and debris during the attacks.
Persons with asthma and their clinicians should be aware of the role environmental and
psychological factors might play in worsening asthma after disasters.
The study data were collected as part of a survey focused primarily on
the psychological impact of the attacks (6). Telephone interviews were conducted during
October 16--November 15, through a random-digit--dialed sample of persons aged >18
years living south of 110th Street in Manhattan. Households were screened for geographic
eligibility, and an adult with the most recent birthday was selected to be interviewed.
Sample weights based on the number of telephones and adults in each household were applied
to adjust for varying probabilities of being interviewed. The response rate was 64.3%. A
total of 1,008 persons were interviewed, of whom 20 were excluded from the analysis
because of missing weight variables. Psychological factors, including life-stressors*,
depression, and risk for post-traumatic stress disorder (PTSD), were assessed by using
questions documented previously (7).
Among participants, 134 (13.4%) reported having been told previously by
a doctor that they had asthma; 75 (58.2%) of those with diagnosed asthma were women. The
median age of the 134 participants with asthma was 36 years (range: 18--78 years); 86
(70.7%) were non-Hispanic whites, 66 (64.8%) had an annual household income of
>$40,000, and 99 (72.2%) had a college or graduate degree. Of the 134 persons with
asthma, 17 (12.1%) reported that they lived or were present south of Canal Street (i.e.,
15 blocks north of the WTC site) at the time of the attacks.
Of the 134 respondents with diagnosed asthma, 34 (27.0%) reported
worsening of asthma symptoms after the September 11 terrorist attacks, defined as having
moderate to severe symptoms during the weeks since September 11 compared with having none
to mild symptoms during the 4 weeks before September 11. Persons with asthma reporting
worsening symptoms were more likely than those not reporting worsening symptoms to report
unscheduled visits to a health-care provider (28% versus 5%; p=0.02) for asthma after
Bivariate analyses showed that an increased severity of asthma symptoms
since September 11 was significantly more likely to be reported by respondents who 1) had
difficulty breathing because of smoke and debris during the attacks, 2) had two or more
life stressors during the 12 months before the attacks, 3) experienced a peri-event panic
attack (i.e., an event that occurred at the time of or shortly after the attacks), 4) had
depression during the preceding month, or 5) had symptoms of PTSD related to the attacks
during the preceding month (Table). Persons with asthma who lived or were present south of
Canal Street on September 11 were more likely than others to report increased asthma
symptoms; however, the association was not statistically significant.
Separate multivariate logistic regression models were used that
included life stressors during the preceding 12 months, peri-event panic attack, PTSD, and
depression and that controlled for age, sex, race/ethnicity, income, and difficulty
breathing because of smoke and debris. Having two or more life stressors during the 12
months before the attacks (odds ratio [OR]=4.4; 95% confidence interval [CI]=1.4--14.2)
remained significantly associated with an increase in asthma severity after September 11;
difficulty breathing because of smoke and debris also was a significant predictor of
worsening asthma after September 11 (OR=7.0; 95% CI=2.3--21.3). Although peri-event panic
attack (OR=2.4; 95% CI=0.8--7.4), PTSD (OR=3.6; 95% CI=0.6--20.9), and depression (OR=2.9;
95% CI=0.9--9.8) also were associated with increased severity in asthma symptoms, the
relation was not statistically significant.
Reported by: J Fagan, PhD, S Galea, MD, J Ahern, MPH, S Bonner, PhD, D Vlahov, PhD, Center
for Urban Epidemiologic Studies, New York Academy of Medicine, New York City. Div of
Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.
Particulate matter and other constituents of smoke can trigger asthma (8). Persons with
asthma who reported difficulty breathing because of smoke and debris during the September
11 attacks might have been particularly sensitive to smoke from the fires that burned at
the WTC site for several weeks. Psychological stress also can worsen asthma (2), and PTSD
has been associated with an increase in respiratory symptoms (9) and with asthma. Even
accounting for the impact of smoke and debris on asthma symptoms, adults with asthma who
had two or more life stressors before September 11 (a risk factor for PTSD) were more
likely to experience worsening of asthma after the attacks.
The findings in this report are subject to at least four limitations. First, no objective
measures are available to validate the self-reported worsening of asthma symptoms in this
population. Second, because of its cross-sectional design, this study could not establish
a temporal or causal relation between worsening of asthma symptoms and psychological
symptoms. Third, some selection bias cannot be ruled out; those with health problems might
have been more or less likely to participate in the survey than others. Finally, because
asthma severity usually increases in the fall (5), these data cannot be used to quantify
the absolute impact on persons with asthma of environmental and psychological factors
related to the September 11 terrorist attacks.
Despite these limitations, the survey data suggest that both the environmental and
psychological sequelae of the September 11 attacks contributed to increasing symptoms
experienced by some persons with asthma during the weeks following the attacks. Persons
with asthma and their clinicians should be aware of the role these factors might play in
worsening asthma after disasters.
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* Include death of a close family member; serious illness or injury; change in marital
status, family, or work situation; or emotional problems.
**Questions or messages regarding errors in formatting should be addressed to
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