After the attack on the World Trade Center, exposure to fire, smoke, and toxic materials in the rubble has left thousands of New York residents with respiratory and sleep complications.

New YorkThe tragic events of September 11 changed life for many people, not only in the United States, but in many parts of the world. The World Trade Center (WTC) was the financial, travel, and commercial heart of the world. The 10-acre site included seven buildings, with each tower footprint about 209 feet square—1 acre.1 The estimated numbers of occupants and visitors at the WTC were at least 50,000 per day.2 This was a devastating blow to the nation’s emotional, physical, mental, and spiritual health. By May 30, 2002, 2,823 people were confirmed to be dead and only 1,058 bodies had been identified.3 This total number includes those on the two airplanes crashing into the WTC.3

There were acute effects of the air contaminants (hazardous exposure to toxic dusts and gases) on the human respiratory system at the WTC disaster site besides the physical hazards associated with rescue-and-search and debris removal operations.4 These included acute occupational exposure to fire, smoke, and toxic materials in the rubble pile following the collapse of the WTC buildings.4 The toxic substances of concern include asbestos from insulation and fireproofing materials, crystalline silica in the concrete, carbon monoxide from fire and engine exhaust, diesel exhaust from vehicles and equipment, mercury from fluorescent lights, chlorodifluoromethane (Freon™ 22) from air conditioning systems, heavy metals from building materials, hydrogen sulfide from sewers, anaerobically decomposing bodies and spoiled food, inorganic acids, volatile organic compounds, and polynuclear aromatic hydrocarbons from fires and engine exhaust.4

The New York City Department of Health requested assistance from the National Institute for Occupational Safety and Health (NIOSH) in evaluating occupational exposure at the site.4 General area and personal breathing zone air samples for many potential air contaminants were collected.4 Environmental sampling from September 18 to October 4 focused on search-and-rescue personnel, heavy equipment operators, and workers cutting metal beams among various other occupations.4 According to their report, most toxic exposures, including asbestos, did not exceed NIOSH-recommended exposure limits or Occupational Safety and Health Administration (OSHA) permissible limits.4,5 Exposure to respirable crystalline silica, despite its presence in the bulk samples, was absent.4 At the time of the NIOSH sampling, the ambient air did not appear to be contaminated with toxic substances from the buildings or their contents or with combustion products to an extent that posed an occupational health hazard.4 One torch cutter was overexposed to cadmium, another worker was overexposed to carbon monoxide while cutting metal beams with an oxyacetylene torch or a gasoline-powered saw, and two more were possibly overexposed to carbon monoxide.4 However, some investigators believe that asbestos fiber contamination was widespread after the WTC collapse, and different government agencies sampling air with different methods reported results in different units, and compared results to different standards.2

In response to the WTC disaster, NIOSH has issued guidelines for addressing a variety of occupational safety and health hazards at disaster sites.6

Health and Safety
From health and safety perspectives, four target populations were involved: building occupants; rescue workers (at least 343 firemen killed); demolition workers; and neighboring residents.2 The phases of rescue operations were also noted, including immediate evacuation (hours), rescue and recovery (about 10 days), demolition and removal of debris (months), followed by a potential for persistent effects.2 For workers and bystanders in phase 1, there were traumatic injuries including acute smoke and fume inhalations, which could ultimately give rise to reactive airways dysfunction syndrome (RADS).2 Among the injuries in the first 3 weeks were chest pain, contusions, lacerations, burns, and various lung injuries (first aid and emergency medical cases records).7

Primary issues for the health and safety of the rescue, recovery, and demolition workers (at least 10,000 individual workers) at the massive disaster site included a comprehensive site safety plan, safety equipment, protective equipment, air monitoring, and surface sampling (it was days to weeks before attempts were made to produce a comprehensive database).2 Overflow of runoff water from the fire suppression activity into the nearby Hudson River contained a number of toxic materials.2 Asbestos emerged as a primary toxic concern for both site workers and neighbors. Asbestos fireproofing was used in the early stages of WTC construction and was then replaced by other materials about halfway through.8 There were known hazardous chemicals stored in bulk on the WTC site. Within the week preceding the attack, 160,000 pounds of a fluorocarbon refrigerant had been delivered and stored in a basement beneath the rubble. While fluorocarbons are mainly hazardous as confined space asphyxiants, there was concern that the ongoing fire could convert this material to phosgene, a highly poisonous gas.2 The initial collapse of the buildings was characterized by production of a massive amount of dust (ash) from crushed concrete, asbestos and other insulation materials, furnishings, paints, and office and janitorial supplies. Dust covered surrounding streets, and rescue workers who had responded before the collapse reported being engulfed in an overwhelmingly thick cloud, which also penetrated hundreds of local buildings, through both broken windows and infiltration of ventilation systems.2 Some of this dust contained significant amounts of condensed lead fumes from paints, and asbestos fibers.2

During phase II, winds carried the smoke plume, or invisible odors, to Brooklyn and New Jersey. In phase III, the intensity of the smoke declined, but the local eddying winds continued to cause rapid shifts in the location of odors from the still smoldering site. Odors were described as burning, plastic, foul, or piercing. Newspapers reported various volatile substances such as benzene and styrene in air samples, with raised concentrations even in November. Symptoms included headaches, mucous membrane symptoms, and burning throats, and seemed to be directly associated with the odors.2

Respiratory Complications
Chronic respiratory problems may develop in rescue workers and nearby residents. WTC cough is being reported by the firefighters. Nearly 11,000 firefighters who responded to the WTC underwent screening for respiratory problems. David Prezant, MD, chief pulmonologist for the New York Fire Department, reported an increase in the number of cases in firefighters of what he called the “WTC cough.”2,3 The symptoms were as severe as acute respiratory distress syndrome (ARDS) requiring mechanical ventilator support, while most had a cough with or without associated sinus infection.3 At least 40% of the firefighters needed medical care for their breathing problems.3 Single or multiple exposures to dust or smoke after the first few days have a likelihood of causing persistent irritant asthma (RADS) or exacerbating RADS.2 The air and the dust may pose a substantial hazard for pregnant women based on detection of dioxins, polychlorinated biphenyls, polycyclic hydrocarbons, and metals.2 The National Institute of Environmental Health Sciences (NIEHS) is organizing prospective research in this field.2

WTC syndrome is a persistent medically unexplained physical symptom among a substantial subset of individuals with varying degrees of exposures. Following war or toxic exposure, individuals may develop three types of health effects including epidemics of physical illness (asbestosis, sarcomas following dioxin exposure); epidemics of psychiatric illness including post-traumatic stress disorder (PTSD)—as in the Vietnam war or Oklahoma City bombing; or epidemics of symptoms not adequately explained by standard diagnosis (Gulf War Syndrome).2.9 This syndrome has also been described for residents near toxic waste sites, where smelling odors synergized with environmental concern is associated with a number of unexplained symptoms.10

Stress Factors
Disaster victims and workers are at risk for acute and chronic PTSD.11 Treatment of established PTSD has only a marginal effect.11 Hence, early intervention to prevent or minimize the establishment of maladaptive and disruptive cognitive or behavioral patterns and, thus, the psychological morbidity following traumatic events is an important component of disaster management.11 Emergency workers are exposed to numerous stressors. Critical incidents during such disasters as the WTC tragedy include deaths in the line of duty, coworkers committing suicide, significant events involving children, incidents involving relatives or knowing the victims, excessive media interest, and disaster or mass casualty events.12 One of the most painful aspects of disaster work is the exposure to sudden, violent death (individuals jumping to their death from the WTC windows at the height of 100 floors), violent death of children, and exposure to dead bodies and body parts.11 Exposure to biohazards adds to such stressors, which are often cited as reasons for increased rates of divorces, substance abuse, and loss of personnel through attrition.11 Cognitive (confusion, disorientation, attention deficits, memory loss, and nightmares), emotional (anger, grief, depression, hopelessness, helplessness, feeling overwhelmed), behavioral (changes in eating habits; sleep disorders like psychophysiological insomnia and chronic insomnia, parasomnia, nightmares; panic attacks and withdrawal), and physical aspects (tachycardia, tachypnea, dizzy spells, hypertension, excessive sweating, and dazed or numbed appearance) are all signs and symptoms of critical incident stress.11,13 Several studies suggest that personnel involved in disaster, especially those involved with the recovery and identification of human remains, are at particular risk for the development of PTSD.14,15

Critical incident stress debriefing (CISD) or psychological debriefing is a brief, structured, interventional technique used immediately or shortly after (48-72 hours) a traumatic event that attempts to assist participants in a group setting in cognitively and emotionally processing their experience.16,17 CISD is now part of a comprehensive spectrum of techniques called critical incident stress management (CISM). This promotes emotional health through verbal expression, cathartic ventilation, normalization of reactions, health education, and preparation for possible future reactions.11 The debriefing technique consists of reviewing the traumatic experience, encouraging emotional expression, and promoting cognitive processing in a group setting.18 This is facilitated by a mental health professional and a peer group not involved in the event. Participants are invited to recount their experiences chronologically and to describe the most terrifying aspects.11 The facilitators teach coping strategies including the importance of resuming normal activities and the value of continued dialogue with friends and family.11 CISD is a part of the systematic approach to CISM that includes preincident stress education programs, on-scene support, peer support programs, follow-up services, and referral procedures.19 Rescue workers and medical or support staff associated with a vast disaster like WTC become victims themselves.11 An infrastructure for CISD should be incorporated into hospital and regional disaster plans including provisions for volunteer and in-hospital workers.11 The 911 dispatchers are also victims of such tragic incidents. The call volume to New Jersey 911 dispatchers increased 66% from 8:00 am to 2:00 pm on the day of the WTC attack. These calls were often from individuals inside the WTC, often long final conversations from anguished, trapped victims asking what to do.11

PTSD has traditionally been associated with exposure to events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others.20 In children, these events usually include exposure to stressors such as war, natural disaster, or emotional, physical, or sexual abuse.20 Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V) mentions that PTSD develops in persons who experience, witness, or are confronted with a traumatic event, it is not clear whether exposure to television programs showing such an event constitutes witnessing a traumatic event.20 There have been reports that children exposed to media coverage of traumatic events can develop significant PTSD symptoms.21 Duggal and coworkers20 reported a case of an 11-year-old boy who developed PTSD along with major depression after watching on television the terrorist attacks on the towers. Five weeks after watching these images while he was in school, he complained feeling “mad, sad, and scared.” He started experiencing repeated images and nightmares of the planes crashing into the WTC and of mangled bodies lying in debris. He became sad and aloof and reported difficulty falling asleep, loss of interest in play, tiredness, and poor appetite. He impulsively decided to commit suicide, but he was prevented by other children in the school. He was referred to a psychiatrist and was diagnosed with major depressive disorder and PTSD. He was started on treatment with paroxetine, which was increased to 30 mg a day. After a month, his depression showed remarkable improvement; the images and avoidance of the event decreased but did not disappear. Media should bear in mind that overenthusiastic news coverage of natural disasters, war, and terrorists attacks may contribute to PTSD symptoms, especially in children.20 Parents need to be aware of potential harmful effects on children of watching news coverage.20

Difede and coworkers22 reported acute psychiatric responses to the explosion at the WTC on February 26, 1993. A bomb exploded in the underground parking lot, and of the approximately 55,000 people who occupied offices in the WTC, an estimated 1,000 people were trapped for up to 9 hours. Six people were killed and approximately 700 people suffered smoke inhalation and other injuries. Patients were evaluated at the Anxiety Disorders Clinic through a referral network organized by the Office of the New York City Commissioner of Mental Health. A structured clinical interview was conducted 1 month following the attack and again 1 year later. A 33-year-old single woman had sustained multiple fractures from the explosion. She was diagnosed with PTSD and reported a heightened sense of vulnerability, helplessness, and difficulty sleeping. Six months after the explosion, she received a 16-week cognitive-behavioral intervention. At follow-up, she did not have PTSD; however, she had quit her job, broken up with her boyfriend, and moved from the New York City area to start her life over again. The investigators suggested that acute interventions might be guided by an examination of how trauma survivors’ fundamental beliefs about themselves, the world, and others have been affected by the event to effectively integrate the experience and obtain symptom relief.22 Cognitive theories of PTSD suggest that exposure to information during a trauma that is contradictory to one’s fundamental beliefs may be associated with the development of symptoms.23

PTSD has been associated with increased sleep-onset latency, decreased sleep efficiency, increased wakefulness after sleep onset, decreased total sleep time, reduction in stage 2 sleep, and increased stage 1 sleep.24 Frequent nightmares are a hallmark of PTSD involving reliving of true experiences and nightmares of gruesome or life-threatening content. Some authors report normal rapid eye movement (REM) sleep while others report reduced REM sleep latency and increased REM density.24 REM sleep behavior disorder is associated with PTSD.25 It has been speculated that PTSD may be a disorder of REM sleep mechanisms, and potent REM-suppressing medications may decrease nightmares and flashbacks.26

Taj M. Jiva, MD, is clinical assistant professor of medicine, State University of New York at Buffalo, and a pulmonologist, intensivist, and sleep specialist at Buffalo Medical Group PC, NY.

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