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1.  Disparities in Mental Health Treatment Following the World Trade Center Disaster: Implications for Mental Health Care and Health Services Research 
Journal of traumatic stress  2005;18(4):287-297.
To assess disparities in mental health treatment in New York City (NYC) after the World Trade Center Disaster (WTCD) reported previously related to care access, we conducted analyses among a cross-sectional survey of adults who had posttraumatic stress disorder (PTSD) or major depression (N = 473) one year after the event. The dependent variables examined were use of mental health services, in general, and use of mental health services related to the WTCD. Similar dependent variables were developed for medication usage. Although a number of bivariate results were statistically significant for postdisaster mental health visits, in a multivariate logistic regression model, only WTCD exposure remained significant. For service utilization related to the WTCD, the multivariate results indicated that African Americans were less likely to have had these visits compared to Whites, while those with a regular doctor, who had greater exposure to WTCD events, and those who had a perievent panic attack were more likely to have had such visits. In terms of medication use, multivariate results suggested that African Americans were less likely to use postdisaster medications, whereas persons 45 + years old and those with a regular doctor, were more likely to use them. For WTCD-related medication use, multivariate models indicated that African Americans were less likely to use medications, relative to Whites, while those between 45 and 64 years old, those with a regular doctor, those exposed to more WTCD events, and those who had a perievent panic attack, were more likely to have taken medications related to the disaster. The primary reason respondents gave for not seeking treatment (55% of subsample) was that they did not believe that they had a problem (73%). Other reasons were that they wanted to solve the problem on their own (5%), had problems accessing services (6%), had financial problems (4%), or had a fear of treatment (4%). Despite the availability of free mental health services offered in a supportive and potentially less stigmatizing environment post disaster, there still appeared to be barriers to receiving postdisaster services among those presumably in need of care.
PMCID: PMC2694751  PMID: 16281225
2.  Patients' request for and emergency physicians' prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak 
BMC Public Health  2005;5:2.
Inappropriate use of antibiotics by individuals worried about biological agent exposures during bioterrorism events is an important public health concern. However, little is documented about the extent to which individuals with self-identified risk of anthrax exposure approached physicians for antimicrobial prophylaxis during the 2001 bioterrorism attacks in the United States.
We conducted a telephone survey of randomly selected members of the Pennsylvania Chapter of the American College of Emergency Physicians to assess patients' request for and emergency physicians' prescription of antimicrobial agents during the 2001 anthrax attacks.
Ninety-seven physicians completed the survey. Sixty-four (66%) respondents had received requests from patients for anthrax prophylaxis; 16 (25%) of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin while 8 physicians prescribed doxycycline.
During the 2001 bioterrorist attacks, the majority of the emergency physicians we surveyed encountered patients who requested anthrax prophylaxis. Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events. Elucidation of the relationship between public health response to outbreaks and outcomes would yield insights to ease burden on frontline clinicians and guide strategies to control inappropriate antibiotic allocation during bioterrorist events.
PMCID: PMC546188  PMID: 15634353
3.  The Anthrax Vaccine and Research: Reactions from Postal Workers and Public Health Professionals 
During the 2001 anthrax attacks, public health agencies faced operational and communication decisions about the use of antibiotic prophylaxis and the anthrax vaccine with affected groups, including postal workers. This communication occurred within an evolving situation with incomplete and uncertain data. Guidelines for prophylactic antibiotics changed several times, contributing to confusion and mistrust. At the end of 60 days of taking antibiotics, people were offered an additional 40 days' supply of antibiotics, with or without the anthrax vaccine, the former constituting an investigational new drug protocol. Using data from interviews and focus groups with 65 postal workers in 3 sites and structured interviews with 16 public health professionals, this article examines the challenges for public health professionals who were responsible for communication with postal workers about the vaccine. Multiple factors affected the response, including a lack of trust, risk perception, disagreement about the recommendation, and the controversy over the military's use of the vaccine. Some postal workers reacted with suspicion to the vaccine offer, believing that they were the subjects of research, and some African American workers specifically drew an analogy to the Tuskegee syphilis study. The consent forms required for the protocol heightened mistrust. Postal workers also had complex and ambivalent responses to additional research on their health. The anthrax attacks present us with an opportunity to understand the challenges of communication in the context of uncertain science and suggest key strategies that may improve communications about vaccines and other drugs authorized for experimental use in future public health emergencies.
PMCID: PMC2963592  PMID: 19117431
4.  Anthrax Lethal Factor as an Immune Target in Humans and Transgenic Mice and the Impact of HLA Polymorphism on CD4+ T Cell Immunity 
PLoS Pathogens  2014;10(5):e1004085.
Bacillus anthracis produces a binary toxin composed of protective antigen (PA) and one of two subunits, lethal factor (LF) or edema factor (EF). Most studies have concentrated on induction of toxin-specific antibodies as the correlate of protective immunity, in contrast to which understanding of cellular immunity to these toxins and its impact on infection is limited. We characterized CD4+ T cell immunity to LF in a panel of humanized HLA-DR and DQ transgenic mice and in naturally exposed patients. As the variation in antigen presentation governed by HLA polymorphism has a major impact on protective immunity to specific epitopes, we examined relative binding affinities of LF peptides to purified HLA class II molecules, identifying those regions likely to be of broad applicability to human immune studies through their ability to bind multiple alleles. Transgenics differing only in their expression of human HLA class II alleles showed a marked hierarchy of immunity to LF. Immunogenicity in HLA transgenics was primarily restricted to epitopes from domains II and IV of LF and promiscuous, dominant epitopes, common to all HLA types, were identified in domain II. The relevance of this model was further demonstrated by the fact that a number of the immunodominant epitopes identified in mice were recognized by T cells from humans previously infected with cutaneous anthrax and from vaccinated individuals. The ability of the identified epitopes to confer protective immunity was demonstrated by lethal anthrax challenge of HLA transgenic mice immunized with a peptide subunit vaccine comprising the immunodominant epitopes that we identified.
Author Summary
Anthrax is of concern with respect to human exposure in endemic regions, concerns about bioterrorism and the considerable global burden of livestock infections. The immunology of this disease remains poorly understood. Vaccination has been based on B. anthracis filtrates or attenuated spore-based vaccines, with more recent trials of next-generation recombinant vaccines. Approaches generally require extensive vaccination regimens and there have been concerns about immunogenicity and adverse reactions. An ongoing need remains for rationally designed, effective and safe anthrax vaccines. The importance of T cell stimulating vaccines is inceasingly recognized. An essential step is an understanding of immunodominant epitopes and their relevance across the diverse HLA immune response genes of human populations. We characterized CD4 T cell immunity to anthrax Lethal Factor (LF), using HLA transgenic mice, as well as testing candidate peptide epitopes for binding to a wide range of HLA alleles. We identified anthrax epitopes, noteworthy in that they elicit exceptionally strong immunity with promiscuous binding across multiple HLA alleles and isotypes. T cell responses in humans exposed to LF through either natural anthrax infection or vaccination were also examined. Epitopes identified as candidates were used to protect HLA transgenic mice from anthrax challenge.
PMCID: PMC4006929  PMID: 24788397
5.  Assessment of Medical Reserve Corps Volunteers' Emergency Response Willingness Using a Threat- and Efficacy-Based Model 
The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency–related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological (“dirty bomb”) emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.
This study investigated the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency–related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey and reported agreement with attitude/belief statements in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological (“dirty bomb”) emergency, and an inhalational anthrax bioterrorism emergency. The volunteers' willingness to respond was found to differ across scenarios and among different attitude/belief statements, with self-efficacy being the primary predictor of willingness to respond.
PMCID: PMC3612278  PMID: 23477632
6.  The Effect of Anthrax Bioterrorism on Emergency Department Presentation 
Study Objective:
From September through December 2001, 22 Americans were diagnosed with anthrax, prompting widespread national media attention and public concern over bioterrorism. The purpose of this study was to determine the effect of the threat of anthrax bioterrorism on patient presentation to a West Coast emergency department (ED).
This survey was conducted at an urban county ED in Oakland, CA between December 15, 2001 and February 15, 2002. During random 8-hour blocks, all adult patients presenting for flu or upper respiratory infection (URI) symptoms were surveyed using a structured survey instrument that included standard visual numerical and Likert scales.
Eighty-nine patients were interviewed. Eleven patients (12%) reported potential exposure risk factors. Eighty percent of patients watched television, read the newspaper, or listened to the radio daily, and 83% of patients had heard about anthrax bioterrorism. Fifty-five percent received a chest x-ray, 10% received either throat or blood cultures, and 28% received antibiotics. Twenty-one percent of patients surveyed were admitted to the hospital. Most patients were minimally concerned that they may have contracted anthrax (mean=3.3±3.3 where 0=no concern and 10=extremely concerned). Patient concern about anthrax had little influence on their decision to visit the ED (mean=2.8±3.0 where 0=no influence and 10=greatly influenced). Had they experienced their same flu or URI symptoms one year prior to the anthrax outbreak, 91% of patients stated they would have sought medical attention.
After considerable exposure to media reports about anthrax, most patients in this urban West Coast ED population were not concerned about anthrax infection. Fear of anthrax had little effect on decisions to come to the ED, and most would have sought medical help prior to the anthrax outbreak.
PMCID: PMC2906971  PMID: 20847852
7.  Quantitative Models of the Dose-Response and Time Course of Inhalational Anthrax in Humans 
PLoS Pathogens  2013;9(8):e1003555.
Anthrax poses a community health risk due to accidental or intentional aerosol release. Reliable quantitative dose-response analyses are required to estimate the magnitude and timeline of potential consequences and the effect of public health intervention strategies under specific scenarios. Analyses of available data from exposures and infections of humans and non-human primates are often contradictory. We review existing quantitative inhalational anthrax dose-response models in light of criteria we propose for a model to be useful and defensible. To satisfy these criteria, we extend an existing mechanistic competing-risks model to create a novel Exposure–Infection–Symptomatic illness–Death (EISD) model and use experimental non-human primate data and human epidemiological data to optimize parameter values. The best fit to these data leads to estimates of a dose leading to infection in 50% of susceptible humans (ID50) of 11,000 spores (95% confidence interval 7,200–17,000), ID10 of 1,700 (1,100–2,600), and ID1 of 160 (100–250). These estimates suggest that use of a threshold to human infection of 600 spores (as suggested in the literature) underestimates the infectivity of low doses, while an existing estimate of a 1% infection rate for a single spore overestimates low dose infectivity. We estimate the median time from exposure to onset of symptoms (incubation period) among untreated cases to be 9.9 days (7.7–13.1) for exposure to ID50, 11.8 days (9.5–15.0) for ID10, and 12.1 days (9.9–15.3) for ID1. Our model is the first to provide incubation period estimates that are independently consistent with data from the largest known human outbreak. This model refines previous estimates of the distribution of early onset cases after a release and provides support for the recommended 60-day course of prophylactic antibiotic treatment for individuals exposed to low doses.
Author Summary
Anthrax poses a potential community health risk due to accidental or intentional aerosol release. We address the need for a transparent and defensible quantitative dose-response model for inhalational anthrax that is useful for risk assessors in estimating the magnitude and timeline of potential public health consequences should a release occur. Our synthesis of relevant data and previous modeling efforts identifies areas of improvement among many commonly cited dose-response models and estimates. To address those deficiencies, we provide a new model that is based on clear, transparent assumptions and published data from human and non-human primate exposures. Our resulting estimates provide important insight into the infectivity to humans of low inhaled doses of anthrax spores and the timeline of infections after an exposure event. These insights are critical to assessment of the impacts of delays in responding to a large scale aerosol release, as well as the recommended course of antibiotic administration to those potentially exposed.
PMCID: PMC3744436  PMID: 24058320
8.  Mass Fatality Management following the South Asian Tsunami Disaster: Case Studies in Thailand, Indonesia, and Sri Lanka 
PLoS Medicine  2006;3(6):e195.
Following natural disasters, mismanagement of the dead has consequences for the psychological well-being of survivors. However, no technical guidelines currently exist for managing mass fatalities following large natural disasters. Existing methods of mass fatality management are not directly transferable as they are designed for transport accidents and acts of terrorism. Furthermore, no information is currently available about post-disaster management of the dead following previous large natural disasters.
Methods and Findings
After the tsunami disaster on 26 December 2004, we conducted three descriptive case studies to systematically document how the dead were managed in Thailand, Indonesia, and Sri Lanka. We considered the following parameters: body recovery and storage, identification, disposal of human remains, and health risks from dead bodies. We used participant observations as members of post-tsunami response teams, conducted semi-structured interviews with key informants, and collected information from published and unpublished documents.
Refrigeration for preserving human remains was not available soon enough after the disaster, necessitating the use of other methods such as dry ice or temporary burial. No country had sufficient forensic capacity to identify thousands of victims. Rapid decomposition made visual identification almost impossible after 24–48 h. In Thailand, most forensic identification was made using dental and fingerprint data. Few victims were identified from DNA. Lack of national or local mass fatality plans further limited the quality and timeliness of response, a problem which was exacerbated by the absence of practical field guidelines or an international agency providing technical support.
Emergency response should not add to the distress of affected communities by inappropriately disposing of the victims. The rights of survivors to see their dead treated with dignity and respect requires practical guidelines and technical support. Mass fatality management following natural disasters needs to be informed by further field research and supported by a network of regional and international forensic institutes and agencies.
Case studies were conducted to systematically document how the bodies of those killed in the tsunami were managed in Thailand, Indonesia, and Sri Lanka. Many lessons can be learned, though more research is needed.
Editors' Summary
Some 226,408 people died in the tsunami that hit countries across South Asia on 26 December 2004. As well as providing assistance to the living, a crucially important part of the disaster relief effort was the recovery, identification, and disposal of the dead. However, there is very little consensus about the best way to handle and identify large numbers of bodies. Although natural disasters that kill many people occur frequently, most guidelines for the management of large numbers of dead bodies have come out of the experience gained from transport accidents and from terrorist incidents, and these guidelines are not directly relevant; for example, natural disasters often cause many more deaths than transport accidents or terrorist attacks. It is important for survivors that the bodies of the dead are handled with respect and that the dead are identified so that survivors know what has happened to missing relatives. However, at the same time many people are afraid of what the effect of many dead bodies might be on the living; one belief is that dead bodies are a source of disease. Such a belief can lead to the inappropriately rapid burial of bodies before identification has been done.
Why Was This Study Done?
The tsunami of 2004 provided an opportunity to study four different aspects of how the dead were handled in a number of different countries: how the bodies were recovered, how the bodies were identified, how the bodies were disposed of, and what, if any, were the health effects of the large number of bodies on survivors. The authors wanted to then use the results to make recommendations for use in future natural disasters.
What Did the Researchers Do and Find?
The authors interviewed in person, in writing, and by E-mail key people involved in the handling of the dead in three of the countries affected by the tsunami: Thailand (where 8,345 people died), Indonesia (where 165,708 people died), and Sri Lanka (where 35,399 people died). The authors discovered that there were a huge number of people and agencies involved in the handling of the dead; for example, in Indonesia 42 different organizations were involved in recovering bodies.
None of the countries had sufficient refrigerated storage available to store bodies until they could be identified. Some effective alternatives were used, such as temporary burial in shallow graves—where the temperature is lower than in the ambient air—with the intention of exhuming the bodies later for identification. However, many bodies were hurriedly buried in mass graves because they were decomposing; these bodies were almost impossible to identify.
Methods and efficiency of identification varied between and within countries. One hospital in Sri Lanka excelled by systematically photographing all bodies brought in and recording sex, height, and personal effects: 87% of the bodies brought here were identified. But in most areas rates of identification were much lower. It seemed that simple methods of identification were the most useful: photographs taken quickly before the bodies started to decompose, dental records, and personal effects found on the bodies. DNA analysis was only useful for a small number of bodies.
When it came to disposal of the bodies, again procedures differed widely, and in some cases were dictated by religious needs—for example, in some Muslim communities all bodies were buried within 24 hours, making counting and identification of the dead very difficult. Mass graves were often used, but these caused problems; for example, haphazard arrangement of the bodies meant that later exhumation and identification would be impossible.
The authors concluded that there was virtually no health impact of the dead bodies on survivors. Other studies found that there were no epidemics among the surviving population, and that most effects were on those who handled bodies in temporary morgues, where there were the expected variety of sharp-implement injuries and mucosal splashes with body fluids, along with heat stress and dehydration due to overuse of personal protective equipment such as respirators.
What Do These Findings Mean?
How efficiently bodies were handled after the tsunami varied widely across and even within countries. The authors conclude that much of this variety was because of a lack of national or local plans for such mass fatalities, along with a lack of practical field guidelines. There was little coordination of all of the different organizations involved. However, in some places bodies were handled very well. The authors drew on their findings to suggest guidelines for the possible future management of large numbers of bodies, and also suggested that further research should be done. Reassuringly, the large numbers of bodies did not cause problems for the survivors, so in the future survivors should be encouraged to systematically identify the dead rather than rushing to bury them because of fear of disease.
Additional Information.
Please access these Web sites via the online version of this summary at
• The World Heath Organization has a Web page that brings together much information on the tsunami and its aftermath
• News from the United Nations special envoy for the tsunami can be found on its Web site
• An article published by the Pan American Health Organization called “Disaster Myths That Just Won't Die”
• Field guidelines for managing mass fatality natural disasters developed by an international workshop following the tsunami
PMCID: PMC1472696  PMID: 16737348
9.  Cost-Effectiveness Comparison of Response Strategies to a Large-Scale Anthrax Attack on the Chicago Metropolitan Area: Impact of Timing and Surge Capacity 
Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.
Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality, but what is the optimal cost-effective response strategy for timing of intervention, public health resources, and critical care facilities? Using a hypothetical large-scale anthrax attack on the Chicago metropolitan area, this study compared response strategies that would begin either 2 days or 5 days after the attack and would consist of administering prophylaxis and vaccine in various combinations. The findings support the government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack.
PMCID: PMC3440066  PMID: 22845046
10.  Trauma Exposure and Posttraumatic Stress Disorder Among Employees of New York City Companies Affected by the September 11, 2001 Attacks on the World Trade Center 
Disaster medicine and public health preparedness  2011;5(0 2):10.1001/dmp.2011.50.
Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD.
Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11–related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision.
The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate’s direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness.
Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.
PMCID: PMC3842159  PMID: 21900416
September 11 attacks; posttraumatic stress disorder; trauma exposure; disaster; disaster mental health services
11.  Attribution of physical complaints to the air disaster in Amsterdam by exposed rescue workers: an epidemiological study using historic cohorts 
BMC Public Health  2006;6:142.
In 1992 a cargo aircraft crashed into a residential area of Amsterdam. A troublesome aftermath followed, with rumors on potential toxic exposures and health consequences. Health concerns remained even though no excess morbidity was predicted in retrospective risk evaluations. This study aimed to assess to what extent the rescue workers attribute long-term physical complaints to this disaster, including its aftermath, and to examine associations between such attribution and types of exposure and background variables.
Historic cohort study that collected questionnaire data on occupational disaster exposure, attribution of physical complaints, and background variables on average 8.5 years post-disaster. For the present study the workers who were exposed to the disaster were selected from the historic cohort, i.e. the professional firefighters (n = 334), police officers (n = 834), and accident and wreckage investigators (n = 241) who performed disaster-related tasks.
Across the three occupational groups, a consistent percentage (ranging from 43% to 49%) of exposed workers with long-term physical complaints attributed these to the disaster, including its aftermath. Those with more physical complaints attributed these to a stronger degree. Multivariate logistic regression analyses showed that attribution was significantly more often reported by firefighters who rescued people, and by police officers who reported the identification and recovery of or search for victims and human remains, clean-up, or security and surveillance of the disaster area; who witnessed the immediate disaster scene; who had a close one affected by the disaster; and who perceived the disaster as the worst thing that ever happened to them. Age, sex and educational level were not significantly associated with attribution.
This study provides further cross-sectional evidence for the role of causal attribution in post-disaster subjective physical health problems. After on average 8.5 years, almost a third (32%) of all the exposed workers, and almost half (45%) of the exposed workers with physical complaints, attributed these complaints to the disaster, including its aftermath. The similarity of the results across the occupational groups suggests a general rather than an occupation-specific attribution process. Longitudinal studies are needed to determine whether causal disaster attribution leads to persistence of post-disaster complaints and health care utilization.
PMCID: PMC1513385  PMID: 16734887
12.  Estimating the Location and Spatial Extent of a Covert Anthrax Release 
PLoS Computational Biology  2009;5(1):e1000356.
Rapidly identifying the features of a covert release of an agent such as anthrax could help to inform the planning of public health mitigation strategies. Previous studies have sought to estimate the time and size of a bioterror attack based on the symptomatic onset dates of early cases. We extend the scope of these methods by proposing a method for characterizing the time, strength, and also the location of an aerosolized pathogen release. A back-calculation method is developed allowing the characterization of the release based on the data on the first few observed cases of the subsequent outbreak, meteorological data, population densities, and data on population travel patterns. We evaluate this method on small simulated anthrax outbreaks (about 25–35 cases) and show that it could date and localize a release after a few cases have been observed, although misspecifications of the spore dispersion model, or the within-host dynamics model, on which the method relies can bias the estimates. Our method could also provide an estimate of the outbreak's geographical extent and, as a consequence, could help to identify populations at risk and, therefore, requiring prophylactic treatment. Our analysis demonstrates that while estimates based on the first ten or 15 observed cases were more accurate and less sensitive to model misspecifications than those based on five cases, overall mortality is minimized by targeting prophylactic treatment early on the basis of estimates made using data on the first five cases. The method we propose could provide early estimates of the time, strength, and location of an aerosolized anthrax release and the geographical extent of the subsequent outbreak. In addition, estimates of release features could be used to parameterize more detailed models allowing the simulation of control strategies and intervention logistics.
Author Summary
Releasing highly pathogenic organisms into an urban population is a form of bioterrorism that could result in a large number of casualties. The first indication that a covert open-air release has occurred is quite likely to be individuals reporting for medical attention. If such an attack is suspected, then public health authorities would attempt to identify those individuals who have been infected in order to provide rapid treatment with the aim of reducing the possibility of disease and potential death. Aiming treatment at too small an area might miss individuals infected further down and/or up wind, whereas issues surrounding both treatment resources and serious side effects may rule out mass treatment campaigns of large sections of the population. Our work provides scientific robustness to firstly estimate where and when an aerosolized release has occurred and secondly identify the most critically affected geographic areas. In order to use this statistical tool during an outbreak, public health workers would only need to collect the time of symptomatic onset and the home and work locations of early cases; recent weather information would also be required. Although the accuracy of the estimates is likely to improve as more cases appear, treating individuals based on early estimates might prove more beneficial since time would be of the essence.
PMCID: PMC2663800  PMID: 19360099
13.  Asthma Beliefs Are Associated with Medication Adherence in Older Asthmatics 
Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics.
To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics.
An observational study of asthma beliefs and self-management among older adults.
Asthmatics ages ≥60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago.
Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence.
The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the “no symptoms, no asthma” belief (58.7 % vs. 31.7 %, respectively, p < 0.001), “will not always have asthma” belief (34.8 % vs. 12.5 %, p < 0.001), and the “MD can cure asthma” belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a “no symptoms, no asthma” belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment.
Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2160-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3539042  PMID: 22878848
asthma; disease management; medication adherence; aging; health beliefs.
14.  Fear of Terrorism and Preparedness in New York City 2 Years After the Attacks: Implications for Disaster Planning and Research 
To help improve disaster planning and research, we studied psychosocial predictors of terrorism fear and preparedness among New York City residents after the World Trade Center disaster (WTCD).
We conducted a random cross-sectional survey of 1,681 adults interviewed 2 years after the WTCD. Participants were living in New York City at the time of the attack and exposed to ongoing terrorist threats.
We found 44.9 percent (95% confidence interval [CI] = 41.9−47.9) of residents were concerned about future attacks and 16.9 percent (95% CI = 14.7−19.3) reported a fear level of “10” on a 10-point analog scale. Furthermore, 14.8 percent (95% CI = 12.8−17.0) reported they had made some plans for a future attack, a significant increase from the previous year. In addition, although 42.6 percent (95% CI = 39.6−45.7) indicated that they would likely wait for evacuation instructions following a chemical, biological, or nuclear attack, 34.4 percent (95% CI = 31.5−37.3) reported they would evacuate immediately against official advice. Predictors of high terrorism fear in a multivariate model included Hispanic ethnicity (odds ratio [OR] = 2.0, P = .006), lower education (OR = 4.4, P < .001, and OR = 3.7, P < .001, respectively, for nonhigh school and high school graduates, compared with college graduates), being exposed to stressful life events (OR = 1.6, P = .048), having current posttraumatic stress disorder (3.1, P < .001), having a fear of death (OR = 2.5, P = .002), and reporting a likelihood of fleeing an attack against advice (OR = 1.5, P = .034). The best predictors of preparedness in a multivariate model was being between 30 to 64 years old (30−44 years old, OR = 2.6, P = .001; 45−64 yeas old, OR = 1.8, P = .03, respectively, compared with 18−29 years old), having higher exposure to the WTCD (moderate exposure, OR = 1.7, P = .05; high exposure, OR = 2.4, P = .002; very high exposure, OR = 4.1, P < .001), respectively, compared with no/little WTCD exposure), and having greater exposure to other lifetime traumatic events (high traumatic event exposure, OR = 2.1, P = .005, compared with no exposure).
Our study suggests that among those exposed to ongoing terrorism threats, terrorism fear and preparedness were related to socioeconomic factors, mental health status, terrorism exposure levels, and exposure to stressful life events.
PMCID: PMC2700549  PMID: 17041297
bioterrorism; community disasters; mental health; preparedness; public health; risk communication; terrorism
15.  Adverse Reactions Associated With Studying Persons Recently Exposed to Mass Urban Disaster 
This study assesses the psychological consequences of participation in a mental health study among people recently exposed to the September 11 attacks. Using cross-sectional telephone surveys, we interviewed random samples of English-speaking or Spanish-speaking adults living in New York City during the attacks 1 year after this event. Altogether, 2,368 people completed the surveys, including a random sample of 1,173 respondents who received mental health services after the attacks. Results indicated that 15% of New Yorkers found some of the survey questions stressful, whereas 28% of those who sought treatment found this to be the case. However, less than 2% reported being upset at survey completion, and among these persons, only four people consented to speak to the study's mental health consultant. Although the majority of those expressing adverse reactions had sought postdisaster treatment, even among these subjects, only 3% were still upset at survey completion, and 2% wanted more information about counseling services. In addition, more than 70% of participants expressed positive sentiments about survey participation. Predictive models indicated that respondents who met study criteria for posttraumatic stress disorder, depression, or anxiety were more likely to find questions stressful, with people having posttraumatic stress disorder or depression the most likely to be upset and to consent to psychiatric consultation at completion. We suggest that, with the proper safeguards, research with persons exposed to a resent mass urban disaster generally can be conducted safely and effectively.
PMCID: PMC2700543  PMID: 15387153
Surveillance; patient safety; bioethics; iatrogenic; posttraumatic stress disorder; PTSD; psychological trauma; community disaster; terrorism
16.  Changes in religious beliefs and the relation of religiosity to posttraumatic stress and life satisfaction after a natural disaster 
To study changes in religious beliefs and predictors of such changes in a community sample exposed to a natural disaster, and to investigate whether religiosity was linked to post-disaster mental distress or life satisfaction.
An adult population of 1,180 Norwegian tourists who experienced the 2004 tsunami was surveyed by a postal questionnaire 2 years after the disaster. Data included religiosity, disaster exposure, general psychopathology, posttraumatic stress and life satisfaction.
Among the respondents, 8% reported strengthening and 5% reported weakening of their religious beliefs. Strengthening was associated with pre-tsunami mental health problems (OR: 1.82, 95% CI: 1.12–2.95) and posttraumatic stress (OR: 1.62, 95% CI: 1.22–2.16). Weakening was associated with younger age (OR: 0.98, 95% CI: 0.96–1.00) and posttraumatic stress (OR: 1.72, 95% CI: 1.23–2.41). Two years after the tsunami, 11% of the sample considered themselves to be positively religious. There were no significant differences in posttraumatic stress, general psychopathology or life satisfaction between religious and non-religious groups.
Religion did not play an important role in the lives of Norwegian tsunami survivors in general. Respondents who had the greatest disaster exposure were more likely to report changes in religious beliefs in both directions. Religious beliefs did not prevent post-disaster long-term mental distress, and religiosity was not related to higher levels of life satisfaction.
PMCID: PMC3173616  PMID: 20676883
Norwegian tourist; 2004 tsunami; Changes in religious beliefs; Religiosity; Posttraumatic stress
17.  Call-Tracking Data and the Public Health Response to Bioterrorism-Related Anthrax 
Emerging Infectious Diseases  2002;8(10):1088-1092.
After public notification of confirmed cases of bioterrorism-related anthrax, the Centers for Disease Control and Prevention’s Emergency Operations Center responded to 11,063 bioterrorism-related telephone calls from October 8 to November 11, 2001. Most calls were inquiries from the public about anthrax vaccines (58.4%), requests for general information on bioterrorism prevention (14.8%), and use of personal protective equipment (12.0%); 882 telephone calls (8.0%) were referred to the state liaison team for follow-up investigation. Of these, 226 (25.6%) included reports of either illness clinically confirmed to be compatible with anthrax or direct exposure to an environment known to be contaminated with Bacillus anthracis. The remaining 656 (74.4%) included no confirmed illness but reported exposures to “suspicious” packages or substances or the receipt of mail through a contaminated facility. Emergency response staff must handle high call volumes following suspected or actual bioterrorist attacks. Standardized health communication protocols that address contact with unknown substances, handling of suspicious mail, and clinical evaluation of suspected cases would allow more efficient follow-up investigations of clinically compatible cases in high-risk groups.
PMCID: PMC2730299  PMID: 12396921
anthrax; bioterrorism; triage; Centers for Disease Control and Prevention
18.  Isolated Case of Bioterrorism-related Inhalational Anthrax, New York City, 2001 
Emerging Infectious Diseases  2003;9(6):689-696.
On October 31, 2001, in New York City, a 61-year-old female hospital employee who had acquired inhalational anthrax died after a 6-day illness. To determine sources of exposure and identify additional persons at risk, the New York City Department of Health, Centers for Disease Control and Prevention, and law enforcement authorities conducted an extensive investigation, which included interviewing contacts, examining personal effects, summarizing patient’s use of mass transit, conducting active case finding and surveillance near her residence and at her workplace, and collecting samples from co-workers and the environment. We cultured all specimens for Bacillus anthracis. We found no additional cases of cutaneous or inhalational anthrax. The route of exposure remains unknown. All environmental samples were negative for B. anthracis. This first case of inhalational anthrax during the 2001 outbreak with no apparent direct link to contaminated mail emphasizes the need for close coordination between public health and law enforcement agencies during bioterrorism-related investigations.
PMCID: PMC3000144  PMID: 12781008
B. anthracis; inhalational anthrax; bioterrorism; research
19.  Attack-Related Life Disruption and Child Psychopathology in New York City Public Schoolchildren 6-Months Post-9/11 
In the aftermath of disasters, understanding relationships between disaster-related life disruption and children’s functioning is key to informing future postdisaster intervention efforts. The present study examined attack-related life disruptions and psychopathology in a representative sample (N = 8,236) of New York City public schoolchildren (Grades 4–12) surveyed 6 months after September 11, 2001. One in 5 youth reported a family member lost their job because of the attacks, and 1 in 3 reported their parents restricted their postattack travel. These forms of disruption were, in turn, associated with elevated rates of probable posttraumatic stress disorder and other anxiety disorders (and major depressive disorder in the case of restricted travel). Results indicate that adverse disaster-related experiences extend beyond traumatic exposure and include the prolonged ripple of postdisaster life disruption and economic hardship. Future postdisaster efforts must, in addition to ensuring the availability of mental health services for proximally exposed youth, maintain a focus on youth burdened by disaster-related life disruption.
PMCID: PMC4110211  PMID: 20589558
20.  Mental health service use 1-year after the World Trade Center disaster: implications for mental health care☆ 
General hospital psychiatry  2004;26(5):346-358.
The objective of this study was to assess prevalence and predictors of mental health service use in New York City (NYC) after the World Trade Center disaster (WTCD). One year after the attacks, we conducted a community survey by telephone of 2368 adults living in NYC on September 11, 2001. In the past year, 19.99% (95% confidence interval [CI]=18.2–21.77) of New Yorkers had mental health visits and 8.1% (95% CI=7.04–9.16) used psychotropic medications. In addition, 12.88% (95% CI=11.51–14.25) reported one or more visits were related to the WTCD. Compared to the year before, 8.57% (95% CI=7.36–9.79) had increased post-disaster visits and 5.28% (95% CI=4.32–6.25) had new post-disaster treatment episodes. Psychotropic medication use related to the WTCD was 4.51% (95% CI=3.75–5.26). Increased postdisaster medication use, compared to the year before, was 4.11% (95% CI=3.35–4.86) and new medication episodes occurred among 3.01% (95% CI=2.34–3.69). In multivariate logistic analyses, mental health visits were associated with younger age, peri-event panic attack, posttraumatic stress disorder (PTSD) and depression. In addition, WTCD-related visits had a positive “dose-response” association with WTCD event exposures (P<0.0001). WTCD-related visits also were positively associated with peri-event panic, anxiety, lower self-esteem, PTSD, and depression. All three medication measures were positively related to PTSD and depression, and negatively associated with African American status. WTCD-related medication use also was positively related to younger age, female gender, WTCD event exposures, negative life events, anxiety and lower self-esteem. Finally, while the percentage of New Yorkers seeking post-disaster treatment did not increase substantially, the volume of visits among patients apparently increased. We conclude that exposure to WTCD events was related to post-disaster PTSD and depression, as well as WTCD-related mental health service use. African Americans were consistently less likely to use post-disaster medications. Although the WTCD did have an impact on treatment-seeking among current patients, it did not substantially increase mental health treatment among the general population.
PMCID: PMC2746086  PMID: 15474634
Mental health service utilization; Psychotropic medications use; Posttraumatic stress disorder; PTSD; Depression; Community disasters; Terrorism
21.  Acute health effects of the Sea Empress oil spill 
STUDY OBJECTIVE: To investigate whether residents in the vicinity of the Sea Empress tanker spill suffered an increase in self reported physical and psychological symptoms, which might be attributable to exposure to crude oil. DESIGN: Retrospective cohort study; postal questionnaire including demographic details, a symptom checklist, beliefs about health effects of oil and the Hospital Anxiety and Depression and SF-36 mental health scales. SETTING: Populations living in four coastal towns on the exposed south Pembrokeshire coast and two control towns on the unexposed north coast. PATIENTS: 539 exposed and 550 unexposed people sampled at random from the family health services authority age-sex register who completed questionnaires. MAIN RESULTS: Adjusted odds ratios for self reported physical symptoms; scores on the Hospital Anxiety and Depression and SF-36 mental health scales, in 1089 people who responded out of a possible 1585 (69%). CONCLUSIONS: Living in areas exposed to the crude oil spillage was significantly associated with higher anxiety and depression scores, worse mental health; and self reported headache (odds ratio = 2.35, 95% CI 1.56, 3.55), sore eyes (odds ratio = 1.96, 95% CI 1.06, 3.62), and sore throat (odds ratio = 1.70, 95% CI 1.12, 2.60) after adjusting for age, sex, smoking status, anxiety, and the belief that oil had affected health. People living in exposed areas reported higher rates of physical and psychological symptoms than control areas. Symptoms significantly associated with exposure after adjustment for anxiety and health beliefs were those expected from the known toxicological effect of oil, suggesting a direct health effect on the exposed population.
PMCID: PMC1756874  PMID: 10396538
22.  The dissemination of anthrax from imported wool: Kidderminster 1900–14 
Background: A century ago anthrax was a continuing health risk in the town of Kidderminster. The distribution of cases in people and in animals provides an indication of the routes by which spores were disseminated. The response to these cases provides an insight into attitudes to an occupational and environmental risk at the time and can be compared with responses in more recent times.
Aims: To assess the distribution of anthrax cases associated with the use of contaminated wool and to review the response to them.
Methods: The area studied was Kidderminster, Worcestershire, England, from 1900 to 1914. Data sources were national records of the Factory Inspectorate and local records from the infirmary, Medical Officer of Health and inquest reports, and county agricultural records, supplemented by contemporary and later review articles. Case reports and summary data were analysed, and discussions and actions taken to improve precautions reviewed.
Results: There were 36 cases of anthrax, with five deaths, one of which was the sole case of the internal form of the disease. Cases of cutaneous anthrax were most frequently found in those handling raw wool, but they also occurred in workers at later stages of the spinning process and in people with little or no recorded exposure to contaminated wool. Limited precautionary measures were in place at the start of the study period. Some improvements were made, especially in the treatment of infections, but wool with a high risk of anthrax contamination continued to be used and cases continued to arise. Major changes were made to the disposal of waste and to agricultural practice in contaminated areas to curtail outbreaks in farm animals.
Conclusions: The introduction of anthrax as a contaminant of imported wool led not only to cases in the highly exposed groups of workers but also to cases in other members of the population and in farm animals. The measures taken during the study period reduced fatalities from cutaneous anthrax but did not eliminate the disease. Public concern about the cases was muted.
PMCID: PMC1740714  PMID: 14739375
23.  Anthrax Infection 
Bacillus anthracis infection is rare in developed countries. However, recent outbreaks in the United States and Europe and the potential use of the bacteria for bioterrorism have focused interest on it. Furthermore, although anthrax was known to typically occur as one of three syndromes related to entry site of (i.e., cutaneous, gastrointestinal, or inhalational), a fourth syndrome including severe soft tissue infection in injectional drug users is emerging. Although shock has been described with cutaneous anthrax, it appears much more common with gastrointestinal, inhalational (5 of 11 patients in the 2001 outbreak in the United States), and injectional anthrax. Based in part on case series, the estimated mortalities of cutaneous, gastrointestinal, inhalational, and injectional anthrax are 1%, 25 to 60%, 46%, and 33%, respectively. Nonspecific early symptomatology makes initial identification of anthrax cases difficult. Clues to anthrax infection include history of exposure to herbivore animal products, heroin use, or clustering of patients with similar respiratory symptoms concerning for a bioterrorist event. Once anthrax is suspected, the diagnosis can usually be made with Gram stain and culture from blood or surgical specimens followed by confirmatory testing (e.g., PCR or immunohistochemistry). Although antibiotic therapy (largely quinolone-based) is the mainstay of anthrax treatment, the use of adjunctive therapies such as anthrax toxin antagonists is a consideration.
PMCID: PMC3361358  PMID: 21852539
Bacillus anthracis; diagnosis; pathogenesis; treatment
24.  The importance of secondary trauma exposure for post-disaster mental disorder 
Interventions to treat mental disorders after natural disasters are important both for humanitarian reasons and also for successful post-disaster physical reconstruction that depends on the psychological functioning of the affected population. A major difficulty in developing such interventions, however, is that large between-disaster variation exists in the prevalence of post-disaster mental disorders, making it difficult to estimate need for services in designing interventions without carrying out a post-disaster mental health needs assessment survey. One of the daunting methodological challenges in implementing such surveys is that secondary stressors unique to the disaster often need to be discovered to understand the magnitude, type, and population segments most affected by post-disaster mental disorders.
This problem is examined in the current commentary by analyzing data from the WHO World Mental Health (WMH) Surveys. We analyze the extent to which people exposed to natural disasters throughout the world also experienced secondary stressors and the extent to which the mental disorders associated with disasters were more proximally due to these secondary stressors than to the disasters themselves.
Lifetime exposure to natural disasters was found to be high across countries (4.4–7.5%). 10.7–11.4% of those exposed to natural disasters reported the occurrence of other related stressors (e.g. death of a loved one and destruction of property). A monotonic relationship was found between the number of additional stressors and the subsequent onset of mental disorders
These results document the importance of secondary stressors in accounting for the effects of natural disasters on mental disorders. Implications for intervention planning are discussed.
PMCID: PMC3465701  PMID: 22670411
Natural disasters; needs assessment; post-disaster intervention planning
25.  Determinants of psychological morbidity in survivors of the earthquake and tsunami in Aceh and Nias 
The goal of this study was to collect information to inform the design of a mental health response following the massive December 2004 earthquake and tsunami in Aceh and North Sumatra, Indonesia. As well as exploring the effect on mental health of direct exposure to the tsunami the study was designed to examine the effect on mental health of immediate post-disaster changes in life circumstances (impact).
Information was collected from a sample of 783 people aged 15 years and over in earthquake and tsunami-affected areas of Aceh and Nias, 616 Internally Displaced Persons (IDPs) and 167 non-IDPs. The structured questionnaire that was designed for data collection consisted of demographic information, measures of disaster exposure and of changes in life circumstances (impact), the extended version of the Self-Reporting Questionnaire (SRQ), and a brief measure of resilience. Group comparisons, contrasting responses of IDPs and non-IDPs, were by chi-square for frequency data and t-tests for ordinal or continuous data. Hierarchical multiple linear regression analyses were performed to examine the relative contributions to psychopathology of demographic variables and measures of exposure, impact and resilience.
High rates of psychopathology, including symptoms of anxiety and affective disorders and post-traumatic stress syndrome, were recorded in the overall sample, particularly in Internally Displaced Persons (IDPs) who experienced more substantial post-disaster changes in life circumstances (impact). The IDP group experienced significantly more SRQ symptoms than did the non-IDP group. Demographic factors alone accounted for less two percent of variance in SRQ-scores. Higher SRQ-20 scores were observed among women, those with lower education, those with diminished resilience beliefs, those experiencing high scores on disaster impact, those experiencing direct exposures to the disaster, and due to (unmeasured) conditions related to being an IDP. The greatest effect among these was due to disaster impacts. The pattern was similar when considering post-traumatic stress symptoms separately.
Negative changes in a person's life circumstances following a disaster appear to have as important an effect on psychopathology as the direct experience of the disaster. Ameliorating the extent and duration of post-disaster negative changes in life circumstances may play an important role in prevention of post-disaster psychological morbidity.
PMCID: PMC2873571  PMID: 20423505

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