Persistent mental and physical health impact of exposure to the September 11, 2001 World Trade Center terrorist attacks.

BACKGROUND: Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. METHODS: We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. RESULTS: In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. CONCLUSIONS: Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Secondhand smoke exposure among nonsmokers nationally and in New York City.

INTRODUCTION: We describe smoking prevalence and secondhand smoke (SHS) exposure among adult nonsmokers in New York City (NYC) across key demographic strata and compare exposure estimates with those found nationally. METHODS: We used serum cotinine data from the 2004 NYC Health and Nutrition Examination Survey (n = 1,767 adults aged 20 years or older) and the 2003-2004 National Health and Nutrition Examination Survey (n = 4,476 adults aged 20 years or older) to assess and compare smoking prevalence and the prevalence of elevated cotinine levels (> or =0.05 ng/ml) among nonsmokers. We conducted multivariate logistic regression to assess independent predictors of elevated cotinine levels in NYC. RESULTS: Although the smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p < .05), the proportion of nonsmoking adults in NYC with elevated cotinine levels was greater than the national average overall (56.7% vs. 44.9%, p < .05) and was higher for most demographic subgroups. In NYC, the highest cotinine levels among nonsmokers were among adults aged 20-39 years, males, and Asians. DISCUSSION: Although NYC enacted comprehensive smoke-free workplace legislation in 2003, findings suggest that exposure to SHS remains a significant public health issue, especially among certain subgroups. The finding of a higher prevalence of SHS exposure in NYC despite lower smoking rates is puzzling but suggests that SHS exposure in dense, urban settings may pose a particular challenge.

Risk factors associated with clinic visits during the 1999 forest fires near the Hoopa Valley Indian Reservation, California, USA.

Forest fires burned near the Hoopa Valley Indian Reservation in northern California from late August until early November in 1999. The fires generated particulate matter reaching hazardous levels. We assessed the relationship between patients seeking care for six health conditions and PM(10) exposure levels during the 1999 fires and during the corresponding period in 1998 when there were no fires. Multivariate logistic regression analysis indicated that daily PM(10) levels in 1999 were significant predictors for patients seeking care for asthma, coronary artery disease and headache after controlling for potential risk factors. Stratified multivariate logistic regression models indicated that daily PM(10) levels in 1999 were significant predictors for patients seeking care for circulatory illness among residents of nearby communities and new patients, and for respiratory illness among residents of Hoopa and those of nearby communities.

Temporal and Spatial Patterns in Utilization of Mental Health Services During and After Hurricane Sandy: Emergency Department and Inpatient Hospitalizations in New York City.

OBJECTIVE: Hurricane Sandy made landfall on October 29, 2012, causing a coastal storm surge and extensive flooding, which led to the closure of several health care facilities in New York City (NYC) and prolonged interruptions in service delivery. The impact on mental health-related emergency department (ED) and inpatient hospital service utilization was studied. METHODS: Data came from the New York Statewide Planning and Research Cooperative System. We obtained mental health-related data among NYC residents from 2010 to 2013. Patients were grouped into 5 geographic areas, including service areas of closed hospitals, the Hurricane Sandy evaluation zone, and all of NYC. The Farrington method was used to detect increases in ED visits and hospitalizations for the post-Sandy period. RESULTS: Open hospitals experienced a substantial increase in psychiatric ED visits from patients living in the service areas of closed hospitals. This surge in psychiatric ED visits persisted for 4 to 6 months after Hurricane Sandy. However, the increase in psychiatric hospitalizations was observed for 1 to 3 months. CONCLUSIONS: Several NYC hospitals received a substantially larger number of ED patients from service areas of closed hospitals after Hurricane Sandy, unlike other hospitals that experienced a decrease. Because of potential surges in the number of psychiatric ED visits, resource allocation to hospitals should be considered. (Disaster Med Public Health Preparedness. 2016;10:512-517).

Increased utilisation of PEPFAR-supported laboratory services by non-HIV patents in Tanzania.

BACKGROUND: It is unknown to what extent the non-HIV population utilises laboratories supported by the President's Emergency Plan for AIDS Relief (PEPFAR). OBJECTIVES: We aimed to describe the number and proportion of laboratory tests performed in 2009 and 2011 for patients referred from HIV and non-HIV services (NHSs) in a convenience sample collected from 127 laboratories supported by PEPFAR in Tanzania. We then compared changes in the proportions of tests performed for patients referred from NHSs in 2009 vs 2011. METHODS: Haematology, chemistry, tuberculosis and syphilis test data were collected from available laboratory registers. Referral sources, including HIV services, NHSs, or lack of a documented referral source, were recorded. A generalised linear mixed model reported the odds that a test was from a NHS. RESULTS: A total of 94 132 tests from 94 laboratories in 2009 and 157 343 tests from 101 laboratories in 2011 were recorded. Half of all tests lacked a documented referral source. Tests from NHSs constituted 42% (66 084) of all tests in 2011, compared with 31% (29 181) in 2009. A test in 2011 was twice as likely to have been referred from a NHS as in 2009 (adjusted odds ratio: 2.0 [95% confidence interval: 2.0-2.1]). CONCLUSION: Between 2009 and 2011, the number and proportion of tests from NHSs increased across all types of test. This finding may reflect increased documentation of NHS referrals or that the laboratory scale-up originally intended to service the HIV-positive population in Tanzania may be associated with a 'spillover effect' amongst the general population.

Spatial Shift in the Utilization of Mental Health Services After Hurricane Sandy Among New York City Residents Enrolled in Medicaid.

OBJECTIVE: Closure of several New York City (NYC) hospitals after Hurricane Sandy caused an unanticipated, extended surge in patient demand at open hospitals. This study identified hospitals with a significant increase in mental-health-related emergency department, inpatient, and outpatient visits from Medicaid patients displaced by Hurricane Sandy. METHODS: NYC Medicaid patients were classified into non-mutually-exclusive geographic categories corresponding to residence in areas served by Bellevue Hospital Center and Coney Island Hospital, the hurricane impact area, and all of NYC. For each geographic region, we compared the observed to the expected number of service visits in the 6 months after the storm. The expected number of visits was calculated from 2-year trends in mental health claims. RESULTS: Twenty-four facilities in all 5 NYC boroughs experienced patient redistribution from storm-affected areas. Eighteen facilities had a concurrent surge in total Medicaid patients, which suggested that redistribution had a greater impact on resource use at these locations. CONCLUSIONS: The redistribution of Medicaid patients after Hurricane Sandy increased mental health service utilization at facilities not near flooded areas. Our findings can aid in surge capacity planning and thereby improve the continuity of mental health care after a natural disaster. (Disaster Med Public Health Preparedness. 2016;10:420-427).

Surveillance for asthma--United States, 1980-1999.

PROBLEM/CONDITION: Asthma, a chronic disease occurring among both children and adults, has been the focus of clinical and public health interventions during recent years. In addition, CDC has outlined a strategy to improve the timeliness and geographic specificity of asthma surveillance as part of a comprehensive public health approach to asthma surveillance. REPORTING PERIOD COVERED: This report presents national data regarding self-reported asthma prevalence, school and work days lost because of asthma, and asthma-associated activity limitations (1980-1996); asthma-associated outpatient visits, asthma-associated hospitalizations, and asthma-associated deaths (1980-1999); asthma-associated emergency department visits (1992-1999); and self-reported asthma episodes or attacks (1997-1999). DESCRIPTION OF SYSTEMS: CDC's National Center for Health Statistics (NCHS) conducts the National Health Interview Survey annually, which includes questions regarding asthma and asthma-related activity limitations. NCHS collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. RESULTS: During 1980-1996, asthma prevalence increased. Annual rates of persons reporting asthma episodes or attacks, measured during 1997-1999, were lower than the previously reported asthma prevalence rates, whereas the rates of lifetime asthma, also measured during 1997-1999, were higher than the previously reported rates. Since 1980, the proportion of children and adults with asthma who report activity limitation has remained stable. Since 1995, the rate of outpatient visits and emergency department visits for asthma increased, whereas the rates of hospitalization and death decreased. Blacks continue to have higher rates of asthma emergency department visits, hospitalizations, and deaths than do whites. INTERPRETATION: Since the previous report in 1998 (CDC. Surveillance for Asthma--United States, 1960-1995. MMWR 1998;47[No. SS-1]:1-28), changes in asthma-associated morbidity and death have been limited. Asthma remains a critical clinical and public health problem. Although data in this report indicate certain early indications of success in current asthma intervention programs (e.g., limited decreases in asthma hospitalization and death rates), the continued presence of substantial racial disparities in these asthma endpoints highlights the need for continued surveillance and targeted interventions.

Self-reported asthma and health-related quality of life: findings from the behavioral risk factor surveillance system.

STUDY OBJECTIVES: Few population-based data regarding the impact of asthma on health-related quality of life in the US adult population are available. DESIGN: Cross-sectional study of participants in 50 states in the United States. SETTING: Using data from 163,773 adult respondents in the 2000 Behavioral Risk Factor Surveillance System, we examined how self-reported asthma is associated with general self-reported health and four health-related quality-of-life measures. RESULTS: Participants with self-reported current asthma reported significantly more age-adjusted physically unhealthy days (6.5 days vs 2.9 days, p < 0.001), mentally unhealthy days (5.2 days vs 3.0 days, p < 0.001), days with activity limitation (3.7 days vs 1.6 days, p < 0.001), and unhealthy physical or mental days (10.0 days vs 5.4 days, p < 0.001) in the last 30 days than participants who never had asthma. After adjusting for age, sex, race or ethnicity, educational attainment, employment status, smoking status, physical activity status, and body mass index, the odds ratios among persons with asthma compared with persons who never had asthma, were 2.41 (95% confidence interval [CI], 2.21 to 2.63) for reporting poor or fair self-rated health, 2.26 (95% CI, 2.06 to 2.49) for reporting >or= 14 days of impaired physical health during the previous 30 days, 1.55 (95% CI, 1.40 to 1.72) for reporting >or= 14 days of poor mental health during the previous 30 days, 1.96 (95% CI, 1.73 to 2.21) for reporting >or= 14 activity limitation days, and 1.99 (95% CI, 1.84 to 2.15) for reporting >or= 14 days of physically or mentally unhealthy days during the previous 30 days. Results were consistent for all age groups, for both sexes, and for all race or ethnic groups. Participants who did not currently have asthma, but had it previously, reported having more unhealthy days with all four measures than participants who never had asthma, but fewer than participants who currently had asthma. CONCLUSIONS: These results provide additional measures to evaluate and monitor the impact of asthma on the health of the US adult population.

Developing laboratory systems and infrastructure for HIV scale-up: A tool for health systems strengthening in resource-limited settings.

The rapid scale-up of HIV care and treatment in resource-limited settings has overwhelmed many public health laboratory services already burdened with human resource shortages, an aging and inadequate infrastructure, and a lack of quality systems. There is, however, a growing appreciation of the opportunity to use HIV-related laboratory strengthening as means to strengthen health systems in general. We briefly describe ongoing efforts to integrate HIV laboratory support into HIV care and treatment systems, thereby strengthening laboratory systems in support of both HIV scale-up and overall health systems strengthening.

Prevalence and control of diabetes and impaired fasting glucose in New York City.

OBJECTIVE: To determine the prevalence of diabetes and impaired fasting glucose (IFG) and to assess clinical management indicators among adults with diabetes in a representative sample of New York City adults. RESEARCH DESIGN AND METHODS: In 2004, New York City implemented the first community-level Health and Nutrition Examination Survey (NYC HANES), modeled after the National Health and Nutrition Examination Survey (NHANES). We used an interview to determine previously diagnosed diabetes and measured fasting plasma glucose to determine undiagnosed diabetes and IFG in a probability sample of 1,336 New York City adults. We assessed glycemic control and other clinical indicators using standardized NHANES protocols. RESULTS: The prevalence of diabetes among New York City adults was 12.5% (95% CI 10.3-15.1): 8.7% diagnosed and 3.8% undiagnosed. Nearly one-fourth (23.5%) of adults had IFG. Asians had the highest prevalence of impaired glucose metabolism (diabetes 16.1%, IFG 32.4%) but were significantly less likely to be obese. Among adults with diagnosed diabetes, less than one-half (45%) had A1C levels <7%; one-half (50%) had elevated blood pressure measures at interview, 43% of whom were not on antihypertensive medications; nearly two-thirds (66%) had elevated LDL levels, and only 10% had their glucose, blood pressure, and cholesterol all at or below recommended levels. Most adults (84%) with diagnosed diabetes were on medication, but only 12% were receiving insulin. CONCLUSIONS: In New York City, diabetes and IFG are widespread. Policies and structural interventions to promote physical activity and healthy eating should be prioritized. Improved disease management systems are needed for people with diabetes.

The National Children's Study: a 21-year prospective study of 100,000 American children.

Prospective, multiyear epidemiologic studies have proven to be highly effective in discovering preventable risk factors for chronic disease. Investigations such as the Framingham Heart Study have produced blueprints for disease prevention and saved millions of lives and billions of dollars. To discover preventable environmental risk factors for disease in children, the US Congress directed the National Institute of Child Health and Human Development, through the Children's Health Act of 2000, to conduct the National Children's Study. The National Children's Study is hypothesis-driven and will seek information on environmental risks and individual susceptibility factors for asthma, birth defects, dyslexia, attention-deficit/hyperactivity disorder, autism, schizophrenia, and obesity, as well as for adverse birth outcomes. It will be conducted in a nationally representative, prospective cohort of 100,000 US-born children. Children will be followed from conception to 21 years of age. Environmental exposures (chemical, physical, biological, and psychosocial) will be assessed repeatedly during pregnancy and throughout childhood in children's homes, schools, and communities. Chemical assays will be performed by the Centers for Disease Control and Prevention, and banks of biological and environmental samples will be established for future analyses. Genetic material will be collected on each mother and child and banked to permit study of gene-environment interactions. Recruitment is scheduled to begin in 2007 at 7 Vanguard Sites and will extend to 105 sites across the United States. The National Children's Study will generate multiple satellite studies that explore methodologic issues, etiologic questions, and potential interventions. It will provide training for the next generation of researchers and practitioners in environmental pediatrics and will link to planned and ongoing prospective birth cohort studies in other nations. Data from the National Children's Study will guide development of a comprehensive blueprint for disease prevention in children.