Psychological factors affecting health after toxicological disasters

Associations Among Environmental Exposures and Physical and Psychiatric Symptoms in a Care-Seeking Sample of U.S. Military Veterans

INTRODUCTION

Recent research and policy (e.g., the Sergeant First Class (SFC) Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act) have highlighted the potential health consequences of toxic environmental exposures. The purpose of the current study was to assess the self-reported prevalence of such exposures among a sample of U.S. military veterans seeking care at a Veterans Affairs facility and to examine associations between exposures and physical and psychiatric symptoms.

MATERIALS AND METHODS

Participants were 4,647 newly enrolling post-9/11 veterans at the VA San Diego Healthcare System who completed standard clinical screening processes between January 2015 and April 2019. Electronic health screening data, including demographic information, military history, environmental exposures, and physical and psychiatric symptoms, were assessed. t-Tests for continuous variables and chi-square tests for categorical variables were used to compare exposed to unexposed veterans on demographic and military characteristics as well as physical and psychiatric symptoms.

RESULTS

A total of 2,028 veterans (43.6%) reported exposure to environmental toxins during their military service. Analyses revealed a disproportionate burden of exposure on older, male, educated, combat veterans as well as Asian and Native American veterans. Exposure to any type of environmental toxin was associated with more physical symptoms, particularly pain, fatigue, and insomnia, as well as psychiatric symptoms, including moderate depressive symptomology, mild to moderate anxiety, and scores approaching the threshold for likely post-traumatic stress disorder and alcohol misuse.

CONCLUSIONS

The high prevalence and detrimental health correlates of environmental exposures underscore the importance of implementing screening for exposures and providing healthcare services that address the multisystemic nature of exposure-related illness.

Health and Psychological Concerns of Communities Affected by Per- and Poly-Fluoroalkyl Substances: The Case of Residents Living in the Orange Area of the Veneto Region

Residents of an extensive area of the Veneto Region (Italy) face one of the largest technological disasters due to per- and polyfluoroalkyl substances (PFAS). On the basis of a risk gradient of contamination, the affected territories were divided into 4 areas: Red (of maximum exposure, where a human biomonitoring programme (HBM) was activated), Orange, Yellow, and Green. This article presents a case study of residents who live in the Orange Area, the second area in terms of contamination, excluded from the HBM. Semi-structured interviews were conducted with 17 residents engaged in promoting a legal procedure to exercise their right to know. Grounded theory and a thematic analysis method were used. Overall, the findings revealed that experiencing contamination causes a negative psychosocial impact on the residents' lives; difficulty accessing information; living with uncertainty, caused by the lack of institutional and health support and medical consultation; a sense of abandonment; difficulty managing preventive and protective actions; and the deterioration of relationships, on the basis of the social comparison with residents of the Red Area, to whom HBM was granted and where the concept of health ostracism has emerged. This study demonstrated that biomonitoring may help reduce discomfort in the case of contamination by informing people of their chemical exposure.

Psychological distress in three Australian communities living with environmental per- and polyfluoroalkyl substances contamination

BACKGROUND

Environmental chemical contamination is a recognised risk factor for psychological distress, but has been seldom studied in the context of per- and polyfluoroalkyl substances (PFAS) contamination. We examined psychological distress in a cross-sectional study of three Australian communities exposed to PFAS from the historical use of aqueous film-forming foam in firefighting activities, and three comparison communities without environmental contamination.

METHODS

Participation was voluntary following recruitment from a PFAS blood-testing program (exposed) or random selection (comparison). Participants provided blood samples and completed a survey on their exposure history, sociodemographic characteristics, and four measures of psychological distress (Kessler-6, Distress Questionnaire-5, Patient Health Questionnaire-15, and Generalised Anxiety Disorder-7). We estimated prevalence ratios (PR) of clinically-significant psychological distress scores, and differences in mean scores: (1) between exposed and comparison communities; (2) per doubling in PFAS serum concentrations in exposed communities; (3) for factors that affect the perceived risk of living in a community exposed to PFAS; and (4) in relation to self-reported health concerns.

RESULTS

We recruited 881 adults in exposed communities and 801 in comparison communities. We observed higher levels of self-reported psychological distress in exposed communities than in comparison communities (e.g., Katherine compared to Alice Springs, Northern Territory: clinically-significant anxiety scores, adjusted PR = 2.82, 95 % CI 1.16-6.89). We found little evidence to suggest that psychological distress was associated with PFAS serum concentrations (e.g., Katherine, PFOS and anxiety, adjusted PR = 0.85, 95 % CI 0.65-1.10). Psychological distress was higher among exposed participants who were occupationally exposed to firefighting foam, used bore water on their properties, or were concerned about their health.

CONCLUSION

Psychological distress was substantially more prevalent in exposed communities than in comparison communities. Our findings suggest that the perception of risks to health, rather than PFAS exposure, contribute to psychological distress in communities with PFAS contamination.

The Psychological Impact of Per- and Poly-Fluoroalkyl Substances (PFAS) Pollution in the Veneto Region, Italy: A Qualitative Study with Parents

Little is known about the psychosocial impact on people who live in polluted areas, and its consequences for the parental role have been neglected. This study addresses this gap, proposing qualitative research referring to the case of per- and poly-fluoroalkyl substances (PFAS) water pollution in the Veneto Region of Italy. The purpose of this study was to investigate the chronic exposure contamination (CEC) experience of parents. Semi-structured interviews were conducted with 32 parents living in the so-called 'Red Area' considered to have had maximum exposure. Grounded theory was used to analyse the data. The three themes to emerge were three phases of a dynamic process: shock around the discovery (phase 1), lifestyle change (phase 2), and living with PFAS (phase 3). The two transitions (loss of innocence and environmental adaptation) linked the phases. Our findings show that PFAS CEC experience is a process whereby parents need to move from the shock of discovery to adapting to the new situation in order to incorporate a change into their daily life, especially in regard to children. Two emerging aspects that characterised the process as a constant were uncertainty and health concerns, while role strains could be a stress source in the context of CEC. We suggest introducing the notion of chronic role strain (CRS).

Chronic environmental contamination: A systematic review of psychological health consequences

We sought to undertake a systematic review to assess the current research and to provide a platform for future research on the psychological health impact of chronic environmental contamination (CEC). CEC is the experience of living in an area where hazardous substances are known or perceived to be present in air, water, or soil at elevated levels for a prolonged and unknown period of time. We employed a systematic review approach to assess the psychological health impact of CEC in literature from 1995 to 2019, and conducted a meta-analysis of available findings (k = 60, N = 25,858) on the impact of CEC on anxiety, general stress, depression, and PTSD. We also present a narrative synthesis of findings that suggest risk factors for the experience of psychological health impacts in the wake of CEC. Likely factors increasing risk for elevated psychological health impact from CEC experience are institutional delegitimization of community concerns and the real or perceived presence of health effects from CEC. The meta-analyses observed small-to-medium effects of experiencing CEC on anxiety, general stress, depression, and PTSD. However, there was also evident risk of bias in the data. Our review suggests that psychological health in the context of CEC is an important potential public health burden and a key area for future improved research.

Chronic environmental contamination: A narrative review of psychosocial health consequences, risk factors, and pathways to community resilience

A body of psychological and social scientific evidence suggests that the experience of technological disaster or long-term exposure to environmental contamination can be psychologically stressful. Addressing the psychosocial impact in communities living with chronic contamination is therefore a vital part of improving their resilience. Guided by a synthetic theoretical model of the unique psychosocial impact of chronic environmental contamination (in contrast to natural and technological disasters, and background pollution), we undertook a narrative review to assess the current research on this important social problem. Relevant qualitative peer-reviewed studies and grey literature were examined to derive a model identifying likely factors increasing risk for distress in chronic contamination experience and actions that may be taken by public health professionals and local leaders to enhance community resilience and take health-protective actions. Based on our initial theoretical model and the literature reviewed, we emphasize the importance of considering both the material and social dimensions of chronic environmental contamination experience. For instance, our review of the qualitative literature suggests that individuals who attribute material health impacts to contamination, and who have the social experience of their concerns being delegitimized by responsible institutions, are most at risk for psychological stress. Psychological stress in the context of chronic contamination is an important potential public health burden and a key area for additional research.

Antenatal and postnatal association of maternal bonding and mental health in Fukushima after the Great East Japan Earthquake of 2011:The Japan Environment and Children's Study (JECS)

BACKGROUND

Japan Environmental and Children's Study (JECS) was under way in Fukushima at the time of the triple disaster. It was initially to assess the effects of environmental factors on children's health, but given the situation particular to the accident, it could also offer an additional source of material with which to examine the psychological impacts of the disaster on mothers. This study aimed to examine the characteristics of mental health of Fukushima mothers after the triple disaster by comparing the scores in Fukushima with the nationwide scores. Then, it aimed to examine associations between their maternal bonding and mental health both during pregnancy and following birth.

METHODS

The JECS administered the Kessler 6-item psychological distress scale (K6) during pregnancy and the Edinburgh Postnatal Depression Scale (EPDS) 1 month following birth to 97 454 eligible women. In conjunction with the JECS, this study analysed the scores of 11 630 women in Fukushima which were obtained in the JECS between 2011 and 2015, and compared them with the nationwide scores during the same time period.

RESULTS

The proportion of mothers having 'negative feelings toward pregnancy' was significantly higher in Fukushima Regional centre (RC) than in the other 13 RCs between 2011 and 2014. No significant difference in the 'lack of affection' scores following birth was found between Fukushima RC and other RCs in 2012 and 2013, but the score in Fukushima RC was significantly lower in 2014 and 2015. The K6 scores in Fukushima RC were significantly higher than in other RCs in all years, and the EPDS scores following birth in Fukushima RC were also higher than in the 13 RCs in all years. The results of multivariate analysis showed a significant association between 'mothers' negative feelings toward pregnancy' and depressive symptoms, except in Fukushima RC in 2011. Also, it showed another significant association between 'lack of affection' and postpartum depressive symptoms from 2012 to 2015 in both Fukushima RC and 13 RCs. K6 scores during pregnancy were significantly associated with EPDS scores throughout the study period in both Fukushima RC and 13 RCs.

LIMITATIONS

Due to the lack of information on participants' residential region at the municipal level in the JECS, it was unable to measure regional differences within Fukushima prefecture.

CONCLUSION

This study shed light on the relationship between maternal bonding and mental health both during pregnancy and following birth by using the sequential and periodic national data sets. While showing the maternal characteristics associated with depressive symptoms during pregnancy and following birth in Japan, it distinguished the characteristics between Fukushima and nationwide. It raised the possibility that providing mothers in Fukushima with supports to increase their bonding toward their pregnancy could prevent the development of depressive tendency. The results could suggest that not only depression prevention measures but also maternal bonding support could be necessary in the region.

Factors Associated With Intention of Future Pregnancy Among Women Affected by the Fukushima Nuclear Accident: Analysis of Fukushima Health Management Survey Data From 2012 to 2014

Background

Little is known about the association between the anxiety toward the effects of radiation on reproduction caused by the Fukushima nuclear accident and the birth rate of people in Fukushima. Therefore, we examined changes and associated factors of future pregnancy intention among mothers in Fukushima Prefecture.

Methods

Using data from three postal surveys among women who registered their pregnancies in the prefecture (N = 6,751 in 2012, N = 6,871 in 2013, and N = 6,725 in 2014), we analyzed the factors associated with women’s intention of future pregnancy using multivariable logistic regression models.

Results

The proportion of mothers with pregnancy intention increased from 53.5% in 2012 to 57.9% in 2014, especially among multiparas (P for trend <0.001). Factors inversely associated with pregnancy intention of both groups were older maternal age (adjusted odds ratio [aOR] 0.92 for primipara and 0.87 for multipara), poor subjective health (aOR 0.75 and 0.81, respectively), and presence of depressive symptoms (aOR 0.71 and 0.79, respectively) (P < 0.01 for all items). In addition, not living with husband (aOR 0.24), dissatisfaction with obstetrical care (aOR 0.89) and child abnormalities (aOR 0.72) were inversely associated with pregnancy intention among primiparas, while receiving infertility treatment (aOR 2.05) was positively associated among multiparas (P < 0.01 for all items). A separate analysis of 2012 and 2013 data showed that concern about radiation contamination of breast milk was associated with pregnancy intention among primiparas (aOR 0.61, P < 0.001).

Conclusions

Mothers’ concern about radiation was associated with lower pregnancy intention, especially among primiparas. Providing quality obstetrical and mental health care and parenting support may be the keys to maintaining the temporal increase in fertility.

Effects of Intimate Partner Violence Versus Poverty on Women's Health

This article investigated whether women's physical health symptoms were due to abuse, poverty, or both. A community sample of 397 women, about half of whom had been assaulted by an intimate partner, were interviewed about their income, experience of physical abuse, and physical health. Hierarchical multiple regression revealed that both income and physical abuse contributed to women's rates of physical health symptoms. Abuse contributed to the variance in physical health beyond that predicted by income level alone. Findings suggest that abuse by an intimate partner or ex-partner negatively affects women's health and is especially detrimental to the health of low-income women.

Immediate effects of the Fukushima nuclear power plant disaster on depressive symptoms among mothers with infants: a prefectural-wide cross-sectional study from the Fukushima Health Management Survey

BACKGROUND

Mothers of young children are at high-risk for developing adverse mental health effects following a nuclear accident. Using the Japanese pregnancy registration system, the prefecture of Fukushima launched a population-based survey of women who were pregnant at the time of the Fukushima nuclear accident in order to assess their and their newborns' health. In this paper, we focus on the results of a screen for depressive symptoms among new mothers and its association with geographical region and interruption of obstetrical care after the Fukushima nuclear accident, which occurred after the Great East Japan Earthquake on March 11, 2011.

METHODS

The survey targeted women who lived in Fukushima prefecture and who had registered their pregnancies between August 1, 2010 and July 31, 2011. Among the 16,001 women targeted, 9,321 returned the questionnaires (response proportion = 58.3%) and data from 8,196 women with singleton live births were analyzed. The main outcome measure was a standard two-item depression screen. Regional radiation levels were determined from the prefecture's periodical reports, and interruption in obstetrical care after the Fukushima nuclear accident was determined from mothers' individual responses to the questionnaire.

RESULTS

Among the 8,196 women, 2,262 (28%) screened positive for depressive symptoms. After adjusting for maternal and infant characteristics, both mothers in Soso, the region in which the nuclear power plant is located, and mothers that had changed obstetrical care facilities were significantly more likely to screen positive for depression. In contrast, mothers in Iwaki and Aizu, regions with relatively low radiation levels, were significantly less likely to screen positive for depression.

CONCLUSIONS

Our findings suggest that improving mental health support for mothers with infants should be a high priority in the acute phase of nuclear disaster response. We further recommend that in the strategic provisioning of parental support, close attention should be paid to regional variations in negative mental health consequences, particularly to those who experienced an interruption in their obstetrical care.

Mental health consequences of chemical and radiologic emergencies: a systematic review

This article reviews the literature pertaining to psychological impacts in the aftermath of technological disasters, focusing on the immediate psychological and mental health consequences emergency department physicians and first responders may encounter in the aftermath of such disasters. First receivers see a wide spectrum of psychological distress, including acute onset of psychiatric disorders, the exacerbation of existing psychological and psychiatric conditions, and widespread symptomatology even in the absence of a diagnosable disorder. The informal community support systems that exist after a natural disaster may not be available to communities affected by a technological disaster leading to a need for more formal mental health supportive services.

Psychosocial care to affected citizens and communities in case of CBRN incidents: a systematic review

Disasters are associated with a substantial psychosocial burden for affected individuals (including first responders) and communities. Knowledge about how to address these risks and problems is valuable for societies worldwide. Decades of research into post-disaster psychosocial care has resulted in various recommendations and general guidelines. However, as CBRN (chemical, biological, radiological, nuclear) events form a distinctive theme in emergency planning and disaster preparedness, it is important to systematically explore their implications for psychosocial care. The aim of this study is to answer two questions: 1). To what extent does psychosocial care in the case of CBRN events differ from other types of events? 2). How strong is the scientific evidence for the effectiveness of psychosocial care interventions in the context of a CBRN event? A systematic literature review was conducted. Searches were performed in Medline, PsychINFO, Embase and PILOTS. Studies since January 2000 were included and evaluated by independent reviewers. The 39 included studies contain recommendations, primarily based on unsystematic literature reviews, qualitative research and expert opinions. Recommendations address: 1) public risk- and crisis communication, 2) training, education and exercise of responders, 3) support, and 4) psychosocial counselling and care to citizens and responders. Although none of the studies meet the design criteria for effectiveness research, a substantial amount of consensus exists on aspects relevant to CBRN related psychosocial care. Recommendations are similar or complementary to general post-disaster psychosocial care guidelines. Notable differences are the emphasis on risk communication and specific preparation needs. Relevant recurring topics are uncertainty about contamination and health effects, how people will overwhelm health care systems, and the possibility that professionals are less likely to respond. However, the lack of evidence on effectiveness makes it necessary to be careful with recommendations. More evaluation research is absolutely needed.

Psychological well-being and risk perceptions of mothers in Kyiv, Ukraine, 19 years after the Chornobyl disaster

BACKGROUND

The Chornobyl nuclear power plant explosion in April 1986 was one of the worst ecological disasters of the 20th century. As with most disasters, its long-term mental health consequences have not been examined.

AIMS

This study describes the psychological well-being and risk perceptions of exposed women 19-20 years later and the risk factors associated with mental health.

METHODS

We assessed Chornobyl-related post-traumatic stress disorder (PTSD), major depressive episode (MDE) and overall distress among three groups of women in Kyiv, Ukraine (N = 797): mothers of small children evacuated to Kyiv in 1986 from the contaminated area near the plant (evacuees); mothers of their children's classmates (neighbourhood controls); and population-based controls from Kyiv. Risk perceptions and epidemiologic correlates were also obtained.

RESULTS

Evacuees reported poorer well-being and more negative risk perceptions than controls. Group differences in psychological well-being remained after adjustment for epidemiologic risk factors but became non-significant when Chornobyl risk perceptions were added to the models.

CONCLUSIONS

The relatively poorer psychological well-being among evacuees is largely explained by their continued concerns about the physical health risks stemming from the accident. We suggest that this is due to the long-term, non-resolvable nature of health fears associated with exposure.

Community stress, psychosocial hazards, and EPA decision-making in communities impacted by chronic technological disasters

Psychosocial stress has emerged as an important consideration in managing environmental health risks. Stress has adverse impacts on health and may interact with environmental hazards to increase health risk. This article's primary objective was to explore psychosocial stress related to environmental contamination. We hypothesized that knowledge about stress should be used in conjunction with chemical risk assessment to inform environmental risk management decisions. Knowledge of psychosocial stress at contaminated sites began by exploring the relationships among social capital, collective efficacy, and contamination at the community level. We discussed stress at the family and individual levels, focusing on stress proliferation, available resources, and coping styles and mechanisms. We then made recommendations on how to improve the use of information on psychosocial stress in environmental decision-making, particularly in communities facing chronic technological disasters.

The psychological well-being of Norwegian adolescents exposed in utero to radiation from the Chernobyl accident

BACKGROUND

On 26 April 1986, the Chernobyl nuclear power plant suffered an accident. Several areas of central Norway were heavily affected by far field radioactive fallout. The present study focuses on the psychological well-being of adolescents who were exposed to this radiation as fetuses.

METHODS

The adolescents (n = 53) and their mothers reported their perceptions of the adolescents' current psychological health as measured by the Youth Self Report and Child Behaviour Checklist.

RESULTS

In spite of previous reports of subtle cognitive deficits in these exposed adolescents, there were few self-reported problems and fewer problems reported by the mothers. This contrasts with findings of studies of children from the former Soviet Union exposed in utero, in which objective measures are inconsistent, and self-reports, especially by mothers, express concern for adolescents' cognitive functioning and psychological well-being.

CONCLUSION

In the current paper, we explore possible explanations for this discrepancy and suggest that protective factors in Norway, in addition to perceived physical and psychological distance from the disaster, made the mothers less vulnerable to Chernobyl-related anxiety, thus preventing a negative effect on the psychological health of both mother and child.

A systematic review of arsenic exposure and its social and mental health effects with special reference to Bangladesh

Underground water in many regions of the world is contaminated with high concentrations of arsenic and the resulting toxicity has created a major environmental and public health problem in the affected regions. Chronic arsenic exposure can cause many diseases, including various physical and psychological harms. Although the physical problems caused by arsenic toxicity are well reported in literature, unfortunately the consequences of arsenic exposure on mental health are not adequately studied. Therefore we conducted a review of the available literature focusing on the social consequences and detrimental effects of arsenic toxicity on mental health. Chronic arsenic exposures have serious implications for its victims (i.e. arsenicosis patients) and their families including social instability, social discrimination, refusal of victims by community and families, and marriage-related problems. Some studies conducted in arsenic affected areas revealed that arsenic exposures are associated with various neurologic problems. Chronic arsenic exposure can lead to mental retardation and developmental disabilities such as physical, cognitive, psychological, sensory and speech impairments. As health is defined by the World Health Organization as "a state of complete physical, mental and social wellbeing", the social dimensions have a large impact on individual's mental health. Furthermore studies in China und Bangladesh have shown that mental health problems (e.g. depression) are more common among the people affected by arsenic contamination. Our study indicates various neurological, mental and social consequences among arsenic affected victims. Further studies are recommended in arsenic-affected areas to understand the underlying mechanisms of poor mental health caused by arsenic exposure.

Offering a medical examination following disaster exposure does not result in long-lasting reassurance about health complaints

OBJECTIVE

This study tested the hypothesis that large-scale provision of individual medical examination will reduce persistent anxiety about health and subjective health complaints after involvement in an aviation disaster with alleged exposure to hazardous chemicals.

METHOD

Three measurements were performed: during the medical examination, 6 weeks later during consultation with the physician and 12 weeks after the first examination. Rescue workers (n=1736) and residents (n=339) involved in the disaster participated. Standardized questionnaires on health complaints and concerns were administered.

RESULTS

Both groups reported increased health anxiety and somatic sensitivity after 12 weeks. Residents reported more posttraumatic stress symptoms, whereas rescue workers seemed to have gained a better quality of life and were somewhat reassured. Participants who attended the consultation with the physician showed increased reassurance scores after 6 weeks, but their worries had increased again on follow-up. However, nonattendees reported more health anxiety on follow-up. More participants judged participation to have had a positive impact, instead of a negative impact, on their health.

CONCLUSION

Our study does not indicate that a large-scale medical examination offered after involvement in a disaster has long-lasting reassuring effects and suggests that such examination may have counterproductive effects by sensitizing participants to health complaints.

Participation in a trauma-focused epidemiological investigation may result in sensitization for current health problems

OBJECTIVES

Participation in health survey research may result in a worsening of self-assessed health status and enhanced service-use by increasing self-awareness of current health status. The present study investigated whether participation in a trauma-focused epidemiological study sensitized participants for health problems irrespective of trauma exposure.

METHODS

A total of 1,019 rescue workers and 453 residents involved in varying degrees in a large scale aviation disaster participated. Data collection took place between December 2000 and April 2003. There were two measurements: one during the epidemiological investigation at a general hospital and one 12 weeks after the first measurement. Follow-up data were gathered in 80% of a randomly selected group of rescue workers and in 62% of the residents. Main outcome measures were: health anxiety, somatic sensitivity, the tendency to be reassured by a physician, psychopathology, post-traumatic stress symptoms, fatigue and quality of life.

RESULTS

Both rescue workers and residents reported less reassurance, and increased health anxiety and somatic sensitivity 12 weeks after the investigation compared to the first measurement. Exposure to the aviation disaster was not predictive of these changes in health perception, but higher levels of psychological and physical symptoms at baseline were. Only 0.2-1.6% of the residents and rescue workers indicated at baseline that the investigation had had a very negative impact on their mental and/or physical well-being. No evidence for systematic trends or changes in baseline scores for anxiety about health or subjective complaints during the 15 months inclusion period were found.

CONCLUSIONS

Participation in an epidemiological study of the long-term sequelae of disaster exposure does not lead to very strong negative reactions in most of the participants, but can result in an increased awareness of somatic sensations, enhancement of health worries and lowered reassurability by physicians, especially in participants with higher levels of psychological and physical symptoms at baseline. Future studies are needed to investigate the temporal stability of these inadvertent and unobtrusive negative consequences.

Chronic arsenic poisoning in drinking water in Inner Mongolia and its associated health effects

Since 1990, a large number of people have been experiencing various health problems from drinking arsenic contaminated water (50-1860 microg/L) in 13 counties of Inner Mongolia, China, most of which are located in the Hetao Plain area. It is calculated that 411,243 people are currently at risk from arsenic poisoning. Clinical and epidemiological investigations were carried out on 13,021 people to ascertain the nature and degree of morbidity that occurred due to chronic arsenic toxicity. In all of the studied patients, 22% had typical hyperkeratosis on the palms or soles and some had raindrop-like hyperpigmentation and depigmentation on the trunk. Other data recorded included subjective and objective symptoms, such as chronic cough (35.0%) and insomnia (37.5%). During physical checkups of 680 villagers in arsenic affected areas, liver function tests showed elevated globulin levels in 6.8% (P value=0.006) of the subjects. Neurotoxicity manifesting as loss of hearing 5.88 (P value=0.005), loss of taste 5.44% (P value=0.001), blurred vision 17.35% (P value=0.000), tingling and numbness of the limbs 33.53% (P value=0.000) and hypertension 8.09% (P value=0.000) were significantly higher in the arsenic affected villages and arsenic pollution also seemed to affect patients' social life and mental health. To solve the problem of arsenic exposure, the quality of drinking water needs to be improved by reducing the arsenic content. We also plan to carry out a survey to detect the incidence and types of cancer among this population.

Making a bad thing worse: Effects of communication of results of an epidemiological study after an aviation disaster

Cognitions attributing health complaints to disaster exposure are associated with more severe health complaints and are therefore a promising target for interventions. Little is known about the best strategy to modify such cognitions following exposure to a technological disaster at the community level. In 1992, a Boeing 747 crashed in a residential area in Amsterdam, the Netherlands. Persisting rumours about the possible toxic cargo of the plane led to increasing health concerns among the residents and rescue workers involved in the disaster. The current study investigates (a) the effectiveness of providing information on the health consequences of exposure to the aviation disaster to residents and rescue workers with varying degrees of exposure to the disaster, and (b) individual characteristics which may moderate the effectiveness of the health information provided. A total of 1019 rescue workers and 453 residents involved with varying degrees in the disaster participated in an epidemiological investigation and 1736 rescue workers and 339 residents, all involved, participated in an individual medical examination. Participants were assessed at baseline and 6 weeks after communication of the results of the epidemiological study. Main outcome measures evaluated health anxiety, somatic sensitivity, reassurance by a physician, psychopathology, post-traumatic stress symptoms, fatigue and quality of life. All participants reported elevated levels of psychopathology and fatigue, increased anxiety and uncertainties about their health 6 weeks after communication of the study results irrespective of the degree of exposure to the disaster. In particular, the conviction that health complaints were caused by toxic exposure was related to more severe health complaints and worries in both rescue workers and residents. Our study shows that communication about the health consequences of exposure to an aviation disaster at the community level has no symptom reducing or reassuring effects. Tailoring of the communication to individual characteristics such as existing expectancies may enhance its impact.

Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts

Medically unexplained symptoms (MUS) are frequently associated with a history of traumatization. The first purpose of the present review paper was to investigate systematically the evidence for such relation in a subset of clinical samples with MUS presenting with functional somatization: chronic pelvic pain, irritable bowel syndrome and conversion and somatization disorder. The second purpose was to critically review three dominant models explaining the relation between trauma and MUS (i.e. dissociation, conversion and hierarchical cognitive models). The latter model in particular adequately accounts for the non-volitional and non-intentional character of MUS and explains how traumata can affect the development of MUS without assuming that previous trauma is a necessary prerequisite of MUS. The cognitive model, however, lacks integration with current neurobiological findings, indicative of central stress-and central nervous system alterations in MUS. The final purpose of the present paper was, therefore, to review current neurobiological studies focused on trauma and MUS and to formulate a research agenda to integrate these neurobiological developments with cognitive models for MUS.

Post-disaster physical symptoms of firefighters and police officers: role of types of exposure and post-traumatic stress symptoms

OBJECTIVES

To examine the relationships between exposure to the air disaster in Amsterdam and multiple physical symptoms among firefighters and police officers, and to explore the role of post-traumatic stress symptoms (PTSS) herein.

DESIGN

Historic cohort study.

METHODS

On average 8.5 years post-disaster, exposed professional firefighters (N=334) and police officers (N=834) and their nonexposed colleagues (N=194 and N=634, respectively) completed questionnaires on disaster exposure and current symptoms. Logistic regression with adjustment for background characteristics was used to compare exposed and nonexposed workers. PTSS were added to these models, as was the interaction between exposure and PTSS, to explore potential mediating and modifying effects, respectively.

RESULTS

Exposed workers reported multiple physical symptoms significantly more often. Multiple physical symptoms seemed to have particularly affected the exposed firefighters who rescued people, and the exposed police officers who supported injured victims and workers, who were involved in the identification of or search for victims and human remains, who witnessed the immediate disaster scene or had a close one affected by the disaster. These exposure effects were essentially independent of PTSS, and no significant interactions between exposure and PTSS were found.

CONCLUSIONS

In conclusion, the excess in post-disaster multiple physical symptoms in exposed workers could not be attributed to PTSS.

Predictors of fatigue in rescue workers and residents in the aftermath of an aviation disaster: a longitudinal study

OBJECTIVES

Although medically unexplained physical symptoms such as fatigue are frequently observed after exposure to trauma, the vast majority of health outcomes studies in trauma and disaster research relates to the psychological and psychiatric problems met by victims. The objectives of this study were to investigate the prevalence of (persistent) fatigue in the aftermath of a disaster and to analyze the predictive value of sociodemographic and various health-related variables for fatigue among both rescue workers and residents.

METHODS

A total of 1951 rescue workers and 753 residents involved in the Bijlmermeer aviation disaster participated in this study. Follow-up data were gathered in 70% of randomly selected rescue workers and 53% of the residents. Multiple regression analyses, multivariate logistic regression analyses, and crosslagged panel analyses examined sociodemographic variables and self-report measures for psychopathology, posttraumatic stress reactions, quality of life, somatosensory amplification, health anxiety, and tendency to be reassured by a physician as predictors of fatigue at baseline and fatigue from baseline to 13 to 28 months follow up.

RESULTS

Elevated levels of fatigue are common after involvement in a disaster in rescue workers (20.6%) and residents (45.4%). Higher levels of psychopathology, lower quality of life, and the tendency to be less reassured were multivariate predictors of both elevated and persistent fatigue. Tendency to be reassured was the most important causal factor for fatigue.

CONCLUSIONS

These results suggest that early identification, adequate reassurance, and treatment of individuals at risk may be worthwhile to prevent chronic fatigue.

Attribution of physical complaints to the air disaster in Amsterdam by exposed rescue workers: an epidemiological study using historic cohorts

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Long term health complaints following the Amsterdam Air Disaster in police officers and fire-fighters

BACKGROUND

On 4 October 1992, a cargo aircraft crashed into apartment buildings in Amsterdam, the Netherlands. Fire-fighters and police officers assisted with the rescue work.

OBJECTIVES

To examine the long term health complaints in rescue workers exposed to a disaster.

METHODS

A historical cohort study was performed among police officers (n = 834) and fire-fighters (n = 334) who performed at least one disaster related task and reference groups of their non-exposed colleagues (n = 634 and n = 194, respectively). The main outcome measures included digestive, cardiovascular, musculoskeletal, nervous system, airway, skin, post-traumatic stress, fatigue, and general mental health complaints; haematological and biochemical laboratory values; and urinalysis outcomes.

RESULTS

Police officers and fire-fighters who were professionally exposed to a disaster reported more physical and mental health complaints, compared to the reference groups. No clinically relevant statistically significant differences in laboratory outcomes were found.

CONCLUSIONS

This study is the first to examine long term health complaints in a large sample of rescue workers exposed to a disaster in comparison to reference groups of non-exposed colleagues. Findings show that even in the long term, and in the absence of laboratory abnormalities, rescue workers report more health complaints.

Psychosocial responses to environmental incidents: a review and a proposed typology

OBJECTIVE

The objective of this review was to propose a typology for understanding the diversity of psychosocial reactions to environmental incidents.

METHODOLOGY

The first section provides an introduction and background to the topic; we then attempt to provide a typology of psychosocial responses to environmental incidents.

RESULTS

Response to an environmental incident can be usefully considered in terms of the exposure, the response of the individual, the action of professionals, the response of the community, and the influence of the society in which the incident occurs. We reviewed each of these factors.

CONCLUSIONS

By examining incidents in an ordered framework, we suggest that a more comprehensive understanding is possible. We also suggest some basic ways in which the psychosocial management of such difficult and diverse incidents could be improved.

Epidemiological study air disaster in Amsterdam (ESADA): study design

Background

In 1992, a cargo aircraft crashed into apartment buildings in Amsterdam, killing 43 victims and destroying 266 apartments. In the aftermath there were speculations about the cause of the crash, potential exposures to hazardous materials due to the disaster and the health consequences. Starting in 2000, the Epidemiological Study Air Disaster in Amsterdam (ESADA) aimed to assess the long-term health effects of occupational exposure to this disaster on professional assistance workers.

Methods/Design

Epidemiological study among all the exposed professional fire-fighters and police officers who performed disaster-related task(s), and hangar workers who sorted the wreckage of the aircraft, as well as reference groups of their non-exposed colleagues who did not perform any disaster-related tasks. The study took place, on average, 8.5 years after the disaster. Questionnaires were used to assess details on occupational exposure to the disaster. Health measures comprised laboratory assessments in urine, blood and saliva, as well as self-reported current health measures, including health-related quality of life, and various physical and psychological symptoms.

Discussion

In this paper we describe and discuss the design of the ESADA. The ESADA will provide additional scientific knowledge on the long-term health effects of technological disasters on professional workers.

Mental health burden amongst inhabitants of an arsenic-affected area in Inner Mongolia, China

Inner Mongolia, China, is an area with high levels of arsenic. The adverse health effects resulting from chronic arsenic exposure include skin keratosis, vascular diseases and cancers. However, the effects of arsenic exposure on mental health have not received much attention. The purpose of this study was to examine the effects of arsenic poisoning on the mental health of the inhabitants of an arsenic-affected area. We performed a cross-sectional study at two villages in Hetao Plain, Inner Mongolia. The populations of both villages were similar in age, sex, lifestyle, socioeconomic conditions, and geographic location. One hundred and thirty four (93.7%) of the 143 inhabitants in the arsenic-affected village and 36 (76.6%) of the 47 inhabitants in the arsenic-free village participated in the study. Subjects with a 30-item version of General Health Questionnaire score of 9 or more were defined as having symptoms of distress. The multiple logistic analyses showed that the mental health of the subjects in the arsenic-affected village was worse than in those in the arsenic-free village (OR=2.5, 95% CI=1.1-6.0). The effect of arsenic on mental health in arsenic-affected areas deserves further investigation. The mental health burden in arsenic-affected areas should be considered in the wider context of public and community health.

Belief in exposure to terrorist agents: reported exposure to nerve or mustard gas by Gulf War veterans

September 11 brought increased awareness that even the threat of chemical and biological terrorism can overwhelm this country's health care system. Belief in exposure to toxic agents, even when none is documented, is not uncommon in crisis and merits vigilant health care evaluation and services. This study examined risk factors (demographics, physical symptoms, clinical diagnosis, exposures, and health status) for belief in exposure to potential terrorist agents (nerve or mustard gas) using a large sample of Gulf War veterans who reported belief in exposure to nerve or mustard gas. We found that females, nonwhites, and those who were older (age 32 to 61 years) were more likely to report exposure. When adjusting for demographics and military service, these veterans reported more exposures (nonnerve or mustard gas) to potentially toxic agents and traumatic events (odds ratio [OR], 6.80; p<.001), reported more physical symptoms during the Gulf War (OR, 2.38; p<.001), were more likely to be diagnosed with a mental disorder (OR, 1.72; p<.001), and reported poorer current health status (OR, 3.47 to 1.22; p<.001). Not unlike previously reported studies of disasters, traumatic exposures, or risk exposures, belief in exposure to toxic agents suggests that certain people are at a greater health care risk. This knowledge will aid in better responding to rapid demands that may be placed on our health care delivery systems in times of potential terrorist activity.