MMWR. Special Issue, September 11, 2002
On September 11, 2001, terrorists attacked and destroyed the World Trade
Center (WTC) in New York City (NYC). An estimated 2,819 persons were reported
killed in the attacks; many others were injured (Office of the Chief Medical
Examiner, New York City Department of Health and Mental Hygiene [NYCDOHMH],
unpublished data, 2002). An estimated 25,000 persons living nearby in lower
Manhattan were affected both physically and emotionally. Many persons witnessed
the attacks; lost family and friends; were exposed to smoke, dust, and debris;
and evacuated their homes. To identify the health-related needs and concerns
of persons residing near the attack site, NYCDOHMH, in collaboration with
CDC, surveyed persons residing in areas immediately surrounding the WTC site.
The primary purpose of the survey was to gather information to set priorities
and direct public health interventions. This report summarizes findings from
the assessment, which indicate that a large proportion of respondents had
physical and psychological symptoms potentially associated with the exposure
and needed information to address their health and safety concerns. On the
basis of the results of the survey, NYCDOHMH responded to resident concerns,
helped reduce exposure to dust and debris, and provided information about
mental health resources.
The survey was conducted door-to-door in three residential areas in
lower Manhattan: Battery Park City, Southbridge Towers, and Independence Plaza
(populations: approximately 8,000, 2,000, and 2,300, respectively)
(Figure 1). These areas represented compact,
well-defined neighborhoods comprising approximately 50% of the residential
population of lower Manhattan. On the basis of data from the NYC Department
of City Planning and on information provided by building managers, a representative
random sample of households were selected, yielding a final sample size of ≥100
households per area. Survey teams composed of NYCDOHMH and CDC staff interviewed
one adult (i.e., person aged ≥18 years) in each household selected.
A standardized questionnaire was developed to obtain information about
household demographics, exposure to the WTC attack, physical and mental health
status, access to services, and urgent needs and concerns. The questionnaire
included the Post-Traumatic Stress Disorder (PTSD) checklist, a validated
17-item screening instrument for symptoms of PTSD based closely on DSM-IV
criteria.1 Data were analyzed using Epi-Info 6.04 and SAS 8.2.
Data from the three surveyed areas were combined and weighted on the basis
of the total number of occupied households in each neighborhood.
With the assistance of building managers and staff, tenant associations,
and other community organizations, survey teams succeeded in contacting 485
of 990 households that had been selected randomly. Uncontacted households
included those that were not yet reoccupied and those whose residents were
unavailable when visited. A total of 71 persons declined to participate; the
overall participation rate was 85.4%. During October 25–November 2,
2001, a total of 414 surveys were completed, including 145 in Battery Park
City, 157 at Southbridge Towers, and 112 at Independence Plaza. Overall, an
estimated 75.1% (95% confidence interval [CI] = 71.8%-78.4%) of households
were evacuated after the attacks. Respondents had a median age of 45 years
(range: 18-92 years), and 16.4% (95% CI = 12.7%-20.1%) had children aged <18
years. An estimated 55.2% (95% CI = 50.1%-60.4%) of the population witnessed
the collapse of the WTC towers, 29.0% (95% CI = 24.2%-33.7%) witnessed persons
being injured or killed, and 48.1% (95% CI = 42.9%-53.2%) knew someone who
died as a result of the attacks.
Although many households lost utility services (i.e., water, electricity,
and gas) after September 11, almost all had functional services at the time
of interview; however, some households still did not have telephone service
(15.5%; 95% CI = 12.1%-18.8%). Approximately half of the population reported
feeling safe in their homes; those not feeling safe were most concerned about
air quality and surface dust. Information about proper cleaning procedures
was received by 61.2% (95% CI = 56.3%-66.2%), and 45.2% (95% CI = 39.9%-50.6%)
reported that their apartments had been cleaned according to recommended methods
of wet mopping hard surfaces and using high-efficiency particulate air (HEPA)
filter vacuums on carpeting. Residents also indicated a need for further information
regarding exposure to dust and debris from the WTC and its effect on health,
recommendations for proper clean up, and availability of both mental health
and relief services.
Symptoms reported most frequently that developed or increased after
September 11 were nose or throat irritations (65.8%; 95% CI = 60.9%-70.7),
eye irritation or infection (49.7%; 95% CI =44.6%-54.9%), and coughing (46.5%;
95% CI = 41.3%-51.6%). At the time of the interviews, these symptoms continued
to be a problem among approximately 82% of the adult population. Few respondents
reported lack of access to medical care (6.6%; 95% CI = 4.1%-9.2%), yet 13.6%
(95% CI = 9.6%-17.5%) reported problems filling prescriptions, primarily because
of problems with phones and transportation.
When asked about symptoms of PTSD, an estimated 38.9% (95% CI = 33.9%-44.0%)
of the adult population scored above the screening cutoff of 43, indicating
a need for further mental health evaluation and a potential for PTSD. An estimated
36.8% (95% CI = 28.9%-44.7%) of this population had received some type of
supportive counseling, compared with 22.7% (95% CI = 16.9%-28.4%) of the population
with scores below the cutoff. Overall, an estimated 28.1% (95% CI = 23.4%-32.8%)
of the adult population had received some type of supportive counseling. A
total of 38.7% (95% CI = 33.6%-43.9%) thought they would benefit from any
or additional supportive counseling; of these, 34.0% (95% CI = 25.8%-42.3%)
reported not having adequate access to this kind of support. When asked about
alcohol use, 14.0% (95% CI = 10.2%-17.7%) reported having used alcohol more
than they meant to since the attack, and 6.5% (95% CI = 3.7%-9.2%) felt that
they needed to decrease their drinking since the attack.
On the basis of the survey results, NYCDOHMH initiated focused outreach
in lower Manhattan neighborhoods through presentations with tenant associations
and community groups to share information and provide a forum for questions
and concerns. Materials were developed and disseminated regarding environmental
issues and related health problems, current air and dust testing results and
their implications, recommendations for cleaning up and reducing further exposures,
psychological effects, and availability of relief services. Materials were
distributed to residential buildings and community organizations, and were
made available at public places (e.g., libraries, stores, and restaurants)
and on NYCDOHMH's website (http://www.nyc.gov/html/doh/pdf/chw/needs1.pdf). NYCDOHMH monitored efforts to maintain dust suppression in the areas
close to the WTC site and communicated closely with other agencies overseeing
the cleanup process around the site. The assessment findings also were shared
with Project Liberty, a disaster recovery program funded by the Federal Emergency
Management Agency that provides outreach, crisis counseling, and public education
services to persons affected by the WTC disaster.
R Kramer, ScD, R Hayes, MA, V Nolan, MPH, S Cotenoff, JD, A Goodman,
MD, New York City Dept of Health and Mental Health. WR Daley, DVM, C Rubin,
DVM, A Henderson, PhD, WD Flanders, MD, National Center for Environmental
Health; N Smith, PhD, EIS Officer, CDC.
This community assessment documented the public health impact of the
WTC attacks on persons living nearby in lower Manhattan. Although basic community
services were available 6 weeks after the attacks, persistent physical and
psychological symptoms were reported among local residents. Residents also
expressed concern about air quality and potential short- and long-term health
effects, especially after Environmental Protection Agency reports of the presence
of asbestos, particulate matter, and volatile organic compounds at the WTC
site. The high proportion of the local population that reported experiencing
health problems potentially related to respiratory irritants supported this
concern. As with other needs assessments conducted soon after a disaster,2,3 this survey provided systematically collected information that could
be used to respond to public concerns and to address the health and mental
health needs of this population.
Although the air quality in lower Manhattan improved with time, resulting
in a reduction of some of the immediate physical impact from the attacks,
the psychological impact remained. The estimated proportion of residents with
increased potential for PTSD is consistent with estimates of PTSD following
other disasters.4,5 These estimates suggest that thousands of persons
residing in lower Manhattan might have been at risk for PTSD and could potentially
benefit from receiving supportive mental health services. A central component
to outreach in this community involved education about the benefits and availability
of supportive counseling services available through Project Liberty.
The findings in this report are subject to at least four limitations.
First, the survey did not include persons who had not yet returned to their
homes. Those who delayed returning might have had more serious psychological
or physical symptoms. Second, because the survey did not include this population,
the estimates for the mean time of evacuation also are underestimated. Third,
no background or comparison data were available to validate the self-reported
assessment of health effects, and these assessments were not verified by health-care
providers. Finally, the indicator of potential for PTSD was not diagnostic.
In response to the assessment, NYCDOHMH conducted extensive outreach,
developed and disseminated informational materials, and provided referral
services to meet community needs. This assessment and its follow-up activities
also provided an opportunity for persons living near the WTC site to voice
their concerns to government agencies in the aftermath of the disaster. NYCDOHMH
was able to provide an important service for this community by giving local
residents timely and comprehensive information. Feedback received from residents
highlights the need to conduct a community assessment as soon as possible
after a disaster.
Because the needs and health effects following a disaster often vary
over time, multiple community assessments might be necessary to monitor these
changes and to reach different populations if evacuations have occurred. The
availability of standardized assessment tools and local health professionals
trained in rapid needs assessment procedures could facilitate understanding
a community's post-disaster needs.
This report is based on data contributed by the New York City Dept of
City Planning; Community HealthWorks, New York City Dept of Health and Mental
Hygiene. Lower Manhattan Community Assessment Team, CDC.
References: 5 available
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