Unmet mental health care need 10-11 years after the 9/11 terrorist attacks: 2011-2012 results from the World Trade Center Health Registry

Bereaved parents' and siblings' healthcare needs, healthcare utilization, and satisfaction with healthcare services eight years after the 2011 Utøya terror attack

Understanding the healthcare needs of bereaved individuals following terrorism is crucial for organizing healthcare services. This cross-sectional study examined the terror-related healthcare needs, healthcare utilization, and satisfaction with professional healthcare among 122 traumatically bereaved parents and siblings eight years after the 2011 Utøya terrorist attack in Norway. Results showed that over 50% of the participants currently needed help coping with their grief or with mental and somatic symptoms, and only 34% were actively utilizing healthcare related to the terror attack. Furthermore, 68% reported not getting sufficient help, suggesting a treatment gap. One-third rated the professional help and treatment as unsatisfactory, with 28% reporting that they had not received competent help. More somatic and posttraumatic stress symptoms were associated with higher healthcare needs, whilst higher levels of insomnia symptoms were associated with lower healthcare satisfaction. This emphasizes the need to recognize, professionally intervene, and provide competent support for traumatically bereaved individuals.

Health care needs, experiences, and satisfaction after terrorism: a longitudinal study of parents of survivors of the Utøya attack

BACKGROUND

There is scarce knowledge on the health care follow-up of parents of terror attack survivors. This study focused on the mothers and fathers of survivors and examined (1) their perceived health care needs relative to their psychological reactions, physical health problems (unmet health care needs), and adaptation to work; (2) whether sociodemographic characteristics, health problems and social support were associated with unmet health care needs; and (3) how unmet health care needs, sociodemographic characteristics, and experiences with health services associated with overall dissatisfaction during the health care follow-up.

METHODS

Interview and questionnaire data from three waves of the Utøya parent study were analyzed (n = 364). Chi-square tests and t- tests were used to compare unmet physical and psychological health care needs, sociodemographic factors and post-terror attack health reported by mothers and fathers. Logistic regression analyses were used to examine whether sociodemographic characteristics, unmet health care needs, and health care experiences were associated with overall dissatisfaction among mothers and fathers of the survivors during the health care follow-up.

RESULTS

Among the mothers, 43% reported unmet health care needs for psychological reactions, while 25% reported unmet health care needs for physical problems. Among the fathers, 36% reported unmet health care needs for psychological reactions, and 15% reported unmet health care needs for physical problems. Approximately 1 in 5 mothers and 1 in 10 fathers reported "very high/high" needs for adaptation to work. Poorer self-perceived health, higher levels of posttraumatic stress and anxiety/depression symptoms, and lower levels of social support were significantly associated with reported unmet psychological and physical health care needs in both mothers and fathers. Parents with unmet health care needs reported significantly lower satisfaction with the help services received compared to parents whose health care needs were met. Low accessibility of help services and not having enough time to talk and interact with health care practitioners were associated with overall dissatisfaction with the help received.

CONCLUSIONS

Our findings highlight that parents of terror-exposed adolescents are at risk of having unmet psychological and physical health care needs and thus need to be included in proactive outreach and health care follow-up programs in the aftermath of a terror attack.

Initiation of multiple-session psychological care in civilians exposed to the November 2015 Paris terrorist attacks

BACKGROUND

Terrorist attacks can induce post-traumatic stress disorder (PTSD) and depression, which require multiple-session psychological care (MSPC). This study aims at investigating MSPC initiation and associated factors.

METHODS

Data were collected from a web-based survey of civilians 8-12 months after their exposure to the November 2015 Paris terrorist attacks. Depression and partial and full PTSD were assessed using the Hospital Anxiety and Depression Scale and the PCL-5 checklist, respectively. Questionnaires collected data on socio-demographic variables, exposure to the attacks, psychological treatment history, social isolation, somatic problems, having received an outreach psychological support (OPS), consultations with a general practitioner, contact with an association for victims, MSPC initiation and, if not, reasons for not having initiated it. Logistic regressions were used to examine factors associated with MSPC initiation.

RESULTS

Among the 450 respondents, 154 reported having initiated a MSPC after the attacks. Of the 134 who provided the MSPC initiation date, 50% did so during the first month. Among the respondents with at least one of the considered psychological disorders, 53% declared not having initiated yet a MSPC. The primary three reasons for not having initiated a MSPC among people with PTSD were "did not feel the need", "it was not the right time to talk about it", and "not offered". For people with at least one psychological disorder, MSPC initiation was associated with the number of somatic problems, type of exposure (witness, threatened, indirectly exposed), prior psychological treatment, being a woman, being in a relationship, having consulted a psychiatrist or a psychologist, having received an OPS, and being in contact with association for victims.

CONCLUSION

The organization of adequate psychological care after a terror attack must take into account the need for healthcare that may emerge several months after the attack, and that witnesses seem less likely to receive MSPC than persons directly threatened despite their psychological disorder. Associations for victims and OPS seem to facilitate access to MSPC. Furthermore, our findings highlight the need to train physicians to screen for psychological disorders in persons exposed to terrorist attacks who present with somatic disorders.

Comment on 'Posttraumatic stress disorder and depression after the 2018 Strasbourg Christmas Market terrorist attack: a comparison of exposed and non-exposed police personnel': moving towards shared methodology in terrorism-research

In the recent article 'Post-traumatic stress disorder and depression following the 2018 Strasbourg Christmas Market terrorist attack: a comparison of exposed and non-exposed police personnel,' important insights are provided about the association between terrorism exposure and Post-Traumatic Stress Disorder (PTSD). However, in our opinion, there are several methodological issues that limit the results of this study. In this letter, we discuss the problematic use of partial PTSD, the adjustment of the PCL-5 to refer only to a specific terrorist attack, and the significance of criterion A.

Mental Health Response to Disasters: Is There a Role for a Primary Care-Based Clinician?

Introduction:

Following natural disasters, rural general practitioners (GPs) are expected to undertake several roles, including identifying those experiencing psychological distress and providing evidence-informed mental health care. This paper reports on a collaborative mental health program developed to support a rural GP practice (population <1,500) and a disaster response service.

Methods:

The program provided specialized disaster mental health care via the placement of a clinician in the GP facility. In collaboration with the GP practice, the program offered opportunistic screening using the Primary Care Posttraumatic Stress Disorder (PTSD) Scale (PC-PTSD) for probable PTSD as the primary measure and the Kessler 6 (K6) as a secondary measure. Those scoring higher than two on the PC-PTSD scale were referred to the mental health clinician (MHC) for further assessment and treatment.

Results:

Sixty screening assessments were completed. Fourteen patients (male = 3; female = 11) scored higher than two on the PC-PTSD. The referred group PC-PTSD mean score was 3.14 and K6 mean score of 19. Those not referred had a PC-PTSD mean score = 0.72 and K6 mean score = 7.30. The treatment and non-treatment groups differed significantly (PC-PTSD: P <.00001 and K6: P <.00001). A prior history of trauma exposure was notable in the intervention group. Eight reported a history of domestic violence, seven histories of sexual abuse, five childhood sexual abuse, and eight intimate partner violence (IPV).

Conclusion:

A post-disaster integrated GP and mental health program in a rural community can assist in identifying individuals experiencing post-disaster psychological distress using opportunistic psychological screening. The findings indicate that collaborative mental health programs may effectively support rural communities post-disaster.

Stress-related psychopathology during the COVID-19 pandemic

The COVID-19 pandemic has introduced widespread societal changes that have required ongoing adaptation. Unsurprisingly, stress-related psychopathology has increased during the pandemic, in both children and adults. We review these patterns through the lens of several leading conceptual models of the link between stress and psychopathology. Some of these models focus on characteristics of environmental stressors-including cumulative risk, specific stressor types, and stress sensitization approaches. Understanding the specific aspects of environmental stressors that are most likely to lead to psychopathology can shed light on who may be in most need of clinical intervention. Other models center on factors that can buffer against the onset of psychopathology following stress and the mechanisms through which stressors contribute to emergent psychopathology. These models highlight specific psychosocial processes that may be most usefully targeted by interventions to reduce stress-related psychopathology. We review evidence for each of these stress models in the context of other widescale community-level disruptions, like natural disasters and terrorist attacks, alongside emerging evidence for these stress pathways from the COVID-19 pandemic. We discuss clinical implications for developing interventions to reduce stress-related psychopathology during the pandemic, with a focus on brief, digital interventions that may be more accessible than traditional clinical services.

Self-Efficacy and Mental Health Help-Seeking Behavior of World Trade Center Health Registry Enrollees, 2015-2016

The September 11th World Trade Center (WTC) disaster resulted in an elevated prevalence of Post-Traumatic Stress Disorder (PTSD) among those directly exposed, yet lower than expected rates of mental health treatment seeking and high levels of reported perceived unmet mental healthcare need were observed in this population in the years following. Self-efficacy, an individual's self-perception of their ability to succeed in specific situations or accomplish a task or goal, may in part explain this discrepancy; however, little is known about its interplay with the help-seeking behaviors of disaster-exposed populations. We used WTC Health Registry data (n = 11,851) to describe the relationship between self-efficacy and three outcomes related to help-seeking behavior: (1) seeking mental health treatment, (2) perceived unmet mental health care needs, and (3) satisfaction with mental health treatment. Multinomial logistic regression models were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI). We found a dose-response relationship between self-efficacy score and mental health help-seeking: for every one unit increase in self-efficacy score, we observed a 6% increase in the odds of having treatment 4 to 12 months ago (OR = 1.06, CI: 1.03-1.09), a 7% increase in the odds of having had treatment 1 to 2 years ago (OR = 1.07, CI: 1.04, 1.09), and a 10% increase in the odds of having sought treatment 2 or more years ago (OR = 1.10, CI: 1.08, 1.12) compared to those who had sought treatment more recently. An understanding of individual self-efficacy may help improve post-disaster mental health treatment in order to provide more tailored and helpful care.

Tourism operator mental health and its relationship with SME organisational resilience during disasters

Crises have a negative, and often long-lasting impact on mental health. The stress of dealing with the ongoing and unpredictable aspects of the COVID-19 pandemic has led to an unprecedented rise in mental health problems including low mood, depression and anxiety. Tourism businesses have faced ongoing challenges, with repeated lockdowns and drastically reduced tourist numbers and mental health challenges faced by operators may impact the resilience of tourism organisations and vice versa. Few studies have examined this. Our study in Victoria, Australia documents the mental health impacts of the COVID-19 crisis on owners and managers (operators) of small to medium tourism businesses and explores organisational factors that may impact or protect operator mental health during the crisis. Our findings show that the mental health of the cohort reached critically low levels over the course of the pandemic. We also identify positive associations between tourism organisational resilience and operator mental health.

Psychosocial care responses to terrorist attacks: a country case study of Norway, France and Belgium

Background

The international terrorism threat urges societies to invest in the planning and organization of psychosocial care. With the aim to contribute to cross-national learning, this study describes the content, target populations and providers of psychosocial care to civilians after terrorist attacks in Norway, France and Belgium.

Methods

We identified and reviewed pre- and post-attack policy documents, guidelines, reports and other relevant grey literature addressing the psychosocial care response to terrorist attacks in Oslo/Utøya, Norway on 22 July 2011; in Paris, France on 13 November 2015; and in Brussels, Belgium on 22 March 2016.

Results

In Norway, there was a primary care based approach with multidisciplinary crisis teams in the local municipalities. In response to the terrorist attacks, there were proactive follow-up programs within primary care and occupational health services with screenings of target groups throughout a year. In France, there was a national network of specialized emergency psychosocial units primarily consisting of psychiatrists, psychologists and psychiatric nurses organized by the regional health agencies. They provided psychological support the first month including guidance for long-term healthcare, but there were no systematic screening programs after the acute phase. In Belgium, there were psychosocial intervention networks in the local municipalities, yet the acute psychosocial care was coordinated at a federal level. A reception centre was organized to provide acute psychosocial care, but there were no reported public long-term psychosocial care initiatives in response to the attacks.

Conclusions

Psychosocial care responses, especially long-term follow-up activities, differed substantially between countries. Models for registration of affected individuals, monitoring of their health and continuous evaluation of countries’ psychosocial care provision incorporated in international guidelines may strengthen public health responses to mass-casualty incidents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07691-2.

Dynamic residential movement and depression among the World Trade Center Health Registry enrollees

PURPOSE

Residential instability is associated with poor mental health, but its causal inference is challenging due to time-varying exposure and confounding, and the role of changing social environments. We tested the association between frequent residential moving and depression risk among adults exposed to the 9/11 disaster.

METHODS

We used four waves of survey data from the World Trade Center Health Registry. We measured residential movement and depression using geocoded annual address records and the Personal Health Questionnaire Depression Scale, respectively, for a prospective cohort of 38,495 adults. We used the longitudinal Targeted Maximum Likelihood Method to estimate depression risk by frequent residential moving and conducted causal mediation analysis to evaluate a mediating role of social environments.

RESULTS

Most enrollees (68%) did not move in 2007-2014, and 6% moved at least once every 4 years. The remaining 26% moved less frequently (e.g., only moving in 2007-2010). Frequent moving versus no moving was associated with risk of depression in 2015-16 (RR = 1.20, 95% CI = 1.06, 1.37). Frequent residential moving-depression pathway was mediated by high social integration (OR = 0.93, 95% CI = 0.90, 0.97).

CONCLUSION

These findings demonstrate the importance of social networks in understanding increased risk of depression associated with housing instability.

Victims of the Terrorist Attacks in Belgium and Professional Mental Health Aid Barriers: A Qualitative Study

Introduction: Terrorist attacks can cause short and long-term stress-reactions, anxiety, and depression among those exposed. Sometimes, professional mental health aid, meaning all types of professional psychotherapy, would be appropriate, but victims often delay or never access mental health aid, even up to a decade after the initial event. Little is known about the barriers terrorist-victims encounter when they try to access professional mental health aid. Method: Using a qualitative design, 27 people exposed to the 22/03/2016 terrorist attack in Belgium were interviewed using half-structured, in-depth interviews, on their experiences with professional mental health aid. A reflexive thematic analysis was employed. Results: Five main barriers for professional mental health aid seeking by victims were found. First, their perception of a lack of expertise of mental health aid professionals. Second, the lack of incentives to overcome their uncertainty to contact a professional. Third, social barriers: people did not feel supported by their social network, feared stigma, or trusted that the support of their social network would be enough to get them through any difficulties. Fourth, a lack of mental health literacy, which seems to be needed to recognize the mental health issues they are facing. Finally, there are financial barriers. The cost of therapy is often too high to begin or continue therapy. Conclusions: This study showed that the barriers for seeking professional mental health aid are diverse and not easily overcome. More mental health promotion is needed, so that there is a societal awareness of possible consequences of being exposed to terrorist attacks, which might result in less stigma, and a quicker realization of possible harmful stress reactions due to a disaster.

Psychological outcomes for young adults after disastrous events: A mixed-methods scoping review

RATIONALE

Young adulthood (18 to 34) is a time of transitional change where individuals can be highly susceptible to mental health concerns. Despite similar vulnerabilities to their adolescent counterparts, the psychological outcomes for young adults following disasters are not well understood.

OBJECTIVE

This scoping review aimed to explore the literature on the psychological outcomes for young adults after disaster events.

METHODS

A systematic search of the literature was conducted in seven electronic databases, including PsycINFO, Medline, CINAHL, PILOTS, EMBASE, Scopus, and ProQuest dissertations and theses global. In total, 91 reports from 15 countries were included.

RESULTS

Findings suggested that young adults experience a range of psychological consequences after disasters, including posttraumatic stress symptoms, depression, anxiety, and other psychological outcomes, such as general/non-specific psychological distress. Pre-disaster, peri-disaster, and post-disaster factors were also found to influence the degree of psychological outcomes experienced by young adults, including prior psychological functioning and disaster exposure, among a host of other factors.

CONCLUSION

Future research is recommended to better understand young adults' psychological outcomes, experiences, and service needs following disasters.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort

BACKGROUND

Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers.

OBJECTIVE

To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders.

METHODS

Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders.

RESULTS

Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers.

CONCLUSIONS

Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.

Mental Healthcare Needs in World Trade Center Responders: Results from a Large, Population-Based Health Monitoring Cohort

Nearly two decades after the 9/11 attacks on the World Trade Center (WTC), the prevalence of mental disorders remains elevated among traditional (e.g., police) and non-traditional (e.g., construction workers) responders who were involved in the WTC rescue, recovery, and clean-up efforts. To date, however, scarce research has examined factors associated with perceived need for mental health care, which is critical to promoting engagement in mental health treatment in this population. Data were analyzed from 16,170 WTC responders, including 8881 police responders and 7289 non-traditional responders, who completed their first annual health monitoring visit with the WTC Health Program an average of 6.5 years after September 11, 2001. Predisposing, enabling, and need-based factors associated with perceived need for mental health care were examined using multivariable logistic regression analyses. Nearly half (48.7%) of non-traditional responders and a fifth (20.6%) of police responders reported a need for mental health care. The most common perceived needs were for psychotropic medication, individual psychotherapy, and stress management counseling. Predisposing (e.g., female gender) and need-based factors (e.g., WTC-related posttraumatic stress disorder) predicted perceived need for mental health care in both groups. Among non-traditional responders, Hispanic ethnicity and current suicidal ideation were additionally associated with this outcome. Non-traditional WTC responders are substantially more likely than police WTC responders to perceive a need for mental health treatment. Characterization of factors associated with perceived need for treatment can help inform population-based outreach and monitoring efforts designed to promote engagement in mental health treatment in WTC responders.

Exposure-Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

We undertook a systematic review to assess the efficacy of exposure-based writing therapies (WTs) for trauma-exposed adults with subthreshold or clinical levels of posttraumatic stress disorder. Four databases (PsycINFO, Medline, Wiley Online, PILOTS) were searched for randomized controlled trials (RCTs) of exposure-based WTs. A total of 13 RCTs that reported on results from 17 WT versus control comparisons were included. The primary outcomes were posttraumatic stress symptom severity at posttreatment and/or clinical response. An overall unclear or high risk of bias was identified in 84.6% of studies. In comparison to both waitlist k = 3, Hedges' g = -0.97, 95% CI [-1.20, -0.73], and placebo writing conditions, k = 9, Hedges' g = -0.48, 95% CI [-0.87, -0.08], WTs were more beneficial to participants. There was no evidence of a difference between WTs that were longer in duration compared to other psychotherapy, k = 2; pooled OR = 1.42; 95% CI [0.83, 2.43]. These findings indicate that exposure-based WTs are effective when compared to waitlist and placebo writing control conditions. The evidence needs to be considered in the context of the modest number of studies conducted to date, the high methodological heterogeneity between the studies, and the high or unclear risk of bias across many studies. Further research is needed to increase the evidence base regarding the efficacy of WTs for posttraumatic stress. Future research should also measure the mediators and predictors of outcomes to further develop protocols and understand which variants of WTs work for different populations or individuals.

Mental health, long-term medication adherence, and the control of asthma symptoms among persons exposed to the WTC 9/11 disaster

Objective: A positive association between mental health conditions and poor asthma control has been documented in the World Trade Center-exposed population. Whether factors such as medication adherence mediate this association is unknown.Methods: The study population was drawn from adult participants of the World Trade Center Health Registry Cohort who self-reported as asthmatic after the disaster and who were currently prescribed a long-term control medication (LTCM). Multivariable linear regression was used to estimate the associations between mental health condition (PTSD, depression, or anxiety) and continuous adherence and Asthma Control Test (ACT) scores.Results: In the study sample of 1,293, 49% were not adherent to their LTCM and two thirds reported poorly or very poorly controlled asthma. Presence of any mental health condition was associated with a 2-point decline in ACT and half a point decrease in adherence scores. However, in the multivariable model, better adherence was statistically significantly associated with slightly worse control.Conclusions: The total effect of mental health on asthma control was opposite in sign from the product of the paths between mental health and adherence and adherence and asthma control; we therefore found no evidence to support the hypothesis that adherence mediated the negative association between poor mental health and adequate asthma control. More research is needed to understand the complex causal mechanisms that underlie the association between mental and respiratory health.

Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris

Background

The use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD).

Methods

Santé publique France conducted a web-based survey of civilians 8–11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims’ or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use.

Results

Two-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps.

Conclusion

Our results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.

The Intentional Self-Medication of 9/11-Related PTSD Symptoms with Alcohol: 15 Years after the Disaster

The self-medication hypothesis may explain the co-morbidity of affective and substance use disorders. Research shows increased prevalence, frequency, and intensity of binge drinking and post-traumatic stress disorder (PTSD) among those directly exposed to the 9/11 terrorist attacks on the World Trade Center (WTC), however, little is known about PTSD symptomology and intentional self-medication with alcohol (ISMA) among this group. We used WTC Health Registry data (N = 28,935) to describe the relationship between ISMA and specific symptom clusters of probable 9/11-related PTSD, the number of PTSD symptom clusters endorsed, and binge drinking intensity. Multivariable logistic regression models were used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CI). ISMA was most strongly associated with the hyperarousal PTSD symptom cluster (AOR = 2.04 [1.88, 2.21]) and the endorsement of one (AOR = 1.80 CI [1.65, 1.95]), two (AOR = 2.51 CI [2.28, 2.77]), or three (AOR = 2.84 CI [2.55, 3.17]) PTSD symptom clusters, indicating a clear dose–response relationship. A significant number of 9/11-exposed persons continue to experience PTSD symptoms and engage in ISMA as a potential coping mechanism. Repeated screenings for self-medicative alcohol use among survivors of mass traumas with PTSD symptoms is of public health importance.

Non-participation and attrition in a longitudinal study of civilians exposed to the January 2015 terrorist attacks in Paris, France

BACKGROUND

Non-participation and attrition are rarely studied despite being important methodological issues when performing post-disaster studies. A longitudinal survey of civilians exposed to the January 2015 terrorist attacks in Paris, France, was conducted 6 (Wave 1) and 18 months (Wave 2) after the attacks. We described non-participation in Wave 1 and determined the factors associated with attrition in Wave 2.

METHODS

Multivariate logistic regression models were used to compare participants in both waves with those who participated in the first wave only. Analyses were performed taking the following factors into account: socio-demographic characteristics, exposure to terror, peri-traumatic reactions, psychological support, perceived social support, impact on work, social and family life, and mental health disorders. Characteristics of new participants in Wave 2 were compared with participants in both waves using a chi-square test.

RESULTS

Of the 390 persons who were eligible to participate in the survey, 190 participated in Wave 1 (participation rate: 49%). The most frequently reported reason for non-participation was to avoid being reminded of the painful event (32%, n = 34/105). In Wave 2, 67 were lost to follow-up, 141 people participated, of whom 123 participated in Wave 1 (re-participation rate: 65%) and 18 were new. Attrition in Wave 2 was associated with socio-demographic characteristics (age, French origin) and location during the attacks, but not with terror exposure or mental health disorders. Compared with those who participated in both waves, new participants declared less social and psychological support since the attacks.

CONCLUSIONS

Attrition at 6 months was not associated with exposure to terror or mental health disorders, which indicates that any bias in future analyses on IMPACTS on mental health outcomes will be limited. Our findings suggest the importance of adapting similar surveys for people of foreign origin and of improving strategies to avoid attrition of younger people, for example by using social media, peers, and the educational environment. The present study also revealed that a high level of exposure to terror and a lack of social and psychological support after a terrorist event could impede individuals' participation in similar surveys in the short term.

Association Between Socioeconomic Status and Asthma-Related Emergency Department Visits Among World Trade Center Rescue and Recovery Workers and Survivors

IMPORTANCE

Although the association between poor economic or social standing and health is well established, few studies have attempted to examine the mediational pathways that produce adverse outcomes in disadvantaged populations.

OBJECTIVE

To determine whether barriers to care mediate the association between socioeconomic status (SES) and asthma-related emergency department (ED) visits.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the World Trade Center Health Registry, which comprises rescue and recovery workers and community members who worked, lived, studied or were otherwise present in downtown Manhattan, New York, during or immediately after the September 11, 2001, disaster. Data were matched to an administrative database of ED visits. Those who experienced an asthma-related ED visit and those who did not were compared in bivariate analysis. A mediation analysis was conducted to determine the role of barriers to care in the association between number of ED visits and SES.

EXPOSURES

Education, income, and race/ethnicity, which were collected at first survey in 2003 to 2004.

MAIN OUTCOMES AND MEASURES

Asthma-related ED visits that occurred after survey responses regarding barriers to care were collected (2006-2007) but before 2016, the latest date that data were available.

RESULTS

The analytic sample included 30 452 enrollees (18 585 [61%] male; median [interquartile range] age, 42.0 [35.0-50.0] years; 20 180 [66%] white, 3834 [13%] African American, and 3961 [13%] Hispanic or Latino [any race]). Approximately half (49%) had less than a bachelor's degree, and 15% had an annual income less than $35 000. Those of lower SES were more likely to experience an asthma-related ED visit. Although number of barriers to care mediated this association, they explained only a small percentage of the overall health disparity (ranging from 3.0% [95% CI, 2.3%-3.9%]) of the differences between African American and white individuals to 9.8% [95% CI, 7.7%-11.9%]) comparing those with less than a high school diploma to those with at least a bachelor's degree. However, the association varied by specific barrier to care. Lack of money, insurance, and transportation mediated up to 11.8% (95% CI, 8.1%-15.9%), 12.5% (95% CI, 8.5%-17.4%), and 4.3% (95% CI, 1.7%-8.4%), respectively, of the association between SES and number of ED visits. Lack of childcare, not knowing where to go for care, and inability to find a health care professional mediated a smaller or no percentage of the association.

CONCLUSIONS AND RELEVANCE

The identification of vulnerable subpopulations is an important goal to reduce the burden of asthma-related hospital care. More research is needed to fully understand all of the pathways that lead disaster survivors of lower SES to disproportionately experience ED visits due to asthma.

Unmet Mental Health Care Needs among Asian Americans 10⁻11 Years After Exposure to the World Trade Center Attack

This study investigated the prevalence of unmet mental health care needs (UMHCN) and their associated factors among 2344 Asian Americans directly exposed to the World Trade Center (WTC) attack 10-11 years afterwards. Given the pervasive underutilization of mental health services among Asians, their subjective evaluation of unmet needs could provide more nuanced information on disparities of service. We used the WTC Health Registry data and found that 12% of Asian Americans indicated UMHCN: 69% attributing it to attitudinal barriers, 36% to cost barriers, and 29% to access barriers. Among all the factors significantly related to UMHCN in the logistic model, disruption of health insurance in the past year had the largest odds ratio (OR = 2.37, 95% confidence interval: 1.61-3.48), though similar to functional impairment due to mental disorders. Post-9/11 mental health diagnosis, probable mental disorder and ≥14 poor mental health days in the past month were also associated with greater odds of UMHCN, while greater social support was associated with lower odds. Results suggest that continued outreach efforts to provide mental health education to Asian communities to increase knowledge about mental illness and treatment options, reduce stigmatization of mental illness, and offer free mental health services are crucial to address UMHCN.

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.

Regional South Australia Health (RESONATE) survey: study protocol

INTRODUCTION

Access to quality healthcare services is considered a moral right. However, for people living in regional locations, timely access to the services that they need may not always be possible because of structural and attitudinal barriers. This suggests that people living in regional areas may have unmet healthcare needs. The aim of this research will be to examine the healthcare needs, expectations and experiences of regional South Australians.

METHODS AND ANALYSIS

The Regional South Australia Health (RESONATE) survey is a cross-sectional study of adult health consumers living in any private or non-private dwelling, in any regional, rural, remote or very remote area of South Australia and with an understanding of written English. Data will be collected using a 45-item, multidimensional, self-administered instrument, designed to measure healthcare need, barriers to healthcare access and health service utilisation, attitudes, experiences and satisfaction. The instrument has demonstrated acceptable psychometric properties, including good content validity and internal reliability, good test-retest reliability and a high level of acceptability. The survey will be administered online and in hard-copy, with at least 1832 survey participants to be recruited over a 12-month period, using a comprehensive, multimodal recruitment campaign.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of the University of South Australia. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.

Firefighters, posttraumatic stress disorder, and barriers to treatment: Results from a nationwide total population survey

Repeated exposure to traumatic experiences may put professional firefighters at increased risk of developing posttraumatic stress disorder (PTSD). To date, however, the rate of PTSD symptoms, unmet need for mental health treatment, and barriers to treatment have only been investigated in subsamples rather than the total population of firefighters. We conducted a nationwide, total population-based survey of all currently employed South Korean firefighters (n = 39,562). The overall response rate was 93.8% (n = 37,093), with 68.0% (n = 26,887) complete responses for all variables. The rate of current probable PTSD was estimated as 5.4%. Among those with current probable PTSD (n = 1,995), only a small proportion (9.7%) had received mental health treatment during the past month. For those who had not received treatment, perceived barriers of accessibility to treatment (29.3%) and concerns about potential stigma (33.8%) were reasons for not receiving treatment. Although those with higher PTSD symptom severity and functional impairment were more likely to seek treatment, greater symptom severity and functional impairment were most strongly associated with increased concerns about potential stigma. This nationwide study points to the need for new approaches to promote access to mental health treatment in professional firefighters.

Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster

IMPORTANCE

Psychiatric interventions offered after natural disasters commonly address subsyndromal symptom presentations, but often remain insufficient to reduce the burden of chronic posttraumatic stress disorder (PTSD).

OBJECTIVE

To simulate a comparison of a stepped care case-finding intervention (stepped care [SC]) vs a moderate-strength single-level intervention (usual care [UC]) on treatment effectiveness and incremental cost-effectiveness in the 2 years after a natural disaster.

DESIGN, SETTING, AND PARTICIPANTS

This study, which simulated treatment scenarios that start 4 weeks after landfall of Hurricane Sandy on October 29, 2012, and ending 2 years later, created a model of 2 642 713 simulated agents living in the areas of New York City affected by Hurricane Sandy.

INTERVENTIONS

Under SC, cases were referred to cognitive behavioral therapy, an evidence-based therapy that aims to improve symptoms through problem solving and by changing thoughts and behaviors; noncases were referred to Skills for Psychological Recovery, an evidence-informed therapy that aims to reduce distress and improve coping and functioning. Under UC, all patients were referred only to Skills for Psychological Recovery.

MAIN OUTCOMES AND MEASURES

The reach of SC compared with UC for 2 years, the 2-year reduction in prevalence of PTSD among the full population, the 2-year reduction in the proportion of PTSD cases among initial cases, and 10-year incremental cost-effectiveness.

RESULTS

This population of 2 642 713 simulated agents was initialized with a PTSD prevalence of 4.38% (115 751 cases) and distributions of sex (52.6% female and 47.4% male) and age (33.9% aged 18-34 years, 49.0% aged 35-64 years, and 17.1% aged ≥65 years) that were comparable with population estimates in the areas of New York City affected by Hurricane Sandy. Stepped care was associated with greater reach and was superior to UC in reducing the prevalence of PTSD in the full population: absolute benefit was clear at 6 months (risk difference [RD], -0.004; 95% CI, -0.004 to -0.004), improving through 1.25 years (RD, -0.015; 95% CI, -0.015 to -0.014). Relative benefits of SC were clear at 6 months (risk ratio, 0.905; 95% CI, 0.898-0.913), with continued gains through 1.75 years (risk ratio, 0.615; 95% CI, 0.609-0.662). The absolute benefit of SC among cases was much stronger, emerging at 3 months (RD, -0.006; 95% CI, -0.007 to -0.005) and increasing through 1.5 years (RD, -0.338; 95% CI, -0.342 to -0.335). Relative benefits of SC among cases were equivalent to those observed in the full population. The incremental cost-effectiveness of SC compared with UC was $3428.71 to $6857.68 per disability-adjusted life year avoided, and $0.80 to $1.61 per PTSD-free day.

CONCLUSIONS AND RELEVANCE

The results of this simulation study suggest that SC for individuals with PTSD in the aftermath of a natural disaster is associated with greater reach than UC, more effectiveness than UC, and is well within the range of acceptability for cost-effectiveness. Results should be considered in light of limitations inherent to agent-based models.

Psychological Distress in Parents and School-Functioning of Adolescents: Results from the World Trade Center Registry

Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.

Adapting to Life after Hurricane Katrina and the Deepwater Horizon Oil Spill: An Examination of Psychological Resilience and Depression on the Mississippi Gulf Coast

The purpose of this study was to examine relationships among depression, psychological resilience, and other sociodemographic factors of individuals who were highly exposed to Hurricane Katrina in 2005 and the Deepwater Horizon Oil Spill in 2010. A spatially stratified random sample of 294 Mississippi Gulf Coast residents living in close proximity to the Gulf of Mexico were surveyed. Findings indicated that low education attainment, financial hardship, and disaster-related damages increased the likelihood of depression, whereas psychological resilience and having health insurance reduced the odds of depression. Implications for enhancing psychological resilience and increasing access to health insurance are discussed.

Mental health status of World Trade Center tower survivors compared to other survivors a decade after the September 11, 2001 terrorist attacks

BACKGROUND

Studies of individuals directly exposed to the World Trade Center (WTC) terrorist attacks of September 11, 2001 have found increased risk for post-traumatic stress disorder (PTSD) and binge drinking (BD). No long-term studies have been conducted on one highly exposed group, WTC tower evacuees.

METHODS

The study sample included 7,695 adult civilians in the WTC Health Registry. Logistic regression was used to examine the odds of PTSD and BD in 1,946 towers evacuees compared to 5,749 others in nearby buildings or on the street.

RESULTS

WTC tower survivors were at increased risk for PTSD and BD compared to the others. Infrastructure and behavioral barriers experienced during evacuation were significantly associated with PTSD.

CONCLUSIONS

WTC tower evacuees are at increased risk for PTSD and BD. Understanding the effects of disaster-related evacuation barriers on the long-term mental health status of survivors can help in the planning of continuing post-disaster treatment. Am. J. Ind. Med. 59:742-751, 2016. © 2016 Wiley Periodicals, Inc.

A PTSD symptoms trajectory mediates between exposure levels and emotional support in police responders to 9/11: a growth curve analysis

BACKGROUND

Exposure to the terrorist attack on the World Trade Center (WTC) on 9/11/2001 resulted in continuing stress experience manifested as Posttraumatic Stress Disorder (PTSD) Symptoms in a minority of the police responders. The WTC Health Registry has followed up a large number of individuals, including police officers, at three waves of data collection from 2003 to 2011. This analysis examines the relationship between initial exposure levels, long-term PTSD symptoms, and subsequent emotional support among police responders.

METHODS

The study population included police responders who had reported their 9/11 exposure levels at Wave 1 (2003/4), provided three waves of data on PTSD symptoms using the 17-item PCL scale, and rated their received emotional support at Wave 3 (N = 2,204, 1,908 men, 296 women, mean age: 38 years at exposure). A second-order growth curve reflected a PTSD symptom trajectory which was embedded in a structural equation model, with exposure level specified as an exogenous predictor, and emotional support specified as an endogenous outcome.

RESULTS

Exposure had a main effect on mean symptom levels (intercept) across three waves but it made no difference in changes in symptoms (slope), and no difference in emotional support. The symptom trajectory, on the other hand, had an effect on emotional support. Its intercept and slope were both related to support, indicating that changes in symptoms affected later emotional support.

CONCLUSIONS

Initial trauma exposure levels can have a long-term effect on mean symptom levels. Emotional support is lower in police responders when PTSD symptoms persist over seven years, but becomes higher when reduction in symptoms occurs.

Police officers who responded to 9/11: Comorbidity of PTSD, depression, and anxiety 10-11 years later

BACKGROUND

After the 9/11/2001 World Trade Center (WTC) attack, many police-responders developed PTSD and might be vulnerable to develop depression and/or anxiety. Comorbidity of PTSD, depression, and/or anxiety is examined.

METHOD

Police enrollees (N = 1,884) from the WTC Health Registry were categorized into four groups based on comorbidity of PTSD, depression, and anxiety. DSM-IV diagnostic criteria for PTSD were used. Depression (PHQ-8) and anxiety (GAD-7) were assessed with standardized psychometric inventories. Multinomial logistic regression was used to identify putative risk factors associated with comorbidity of PTSD.

RESULTS

Of 243 (12.9% of total) police with probable PTSD, 21.8% had probable PTSD without comorbidity, 24.7% had depression, 5.8% had anxiety, and 47.7% had comorbid depression and anxiety. Risk factors for comorbid PTSD, depression, and anxiety include being Hispanic, decrease in income, experiencing physical injury on 9/11, experiencing stressful/traumatic events since 9/11, and being unemployed/retired.

CONCLUSION

Nearly half of police with probable PTSD had comorbid depression and anxiety. Am. J. Ind. Med. 59:425-436, 2016. © 2016 Wiley Periodicals, Inc.

Hurricane Sandy Evacuation Among World Trade Center Health Registry Enrollees in New York City

Objective

Timely evacuation is vital for reducing adverse outcomes during disasters. This study examined factors associated with evacuation and evacuation timing during Hurricane Sandy among World Trade Center Health Registry (Registry) enrollees.

Methods

The study sample included 1162 adults who resided in New York City’s evacuation zone A during Hurricane Sandy who completed the Registry’s Hurricane Sandy substudy in 2013. Factors assessed included zone awareness, prior evacuation experience, community cohesion, emergency preparedness, and poor physical health. Prevalence estimates and multiple logistic regression models of evacuation at any time and evacuation before Hurricane Sandy were created.

Results

Among respondents who evacuated for Hurricane Sandy (51%), 24% had evacuated before the storm. In adjusted analyses, those more likely to evacuate knew they resided in an evacuation zone, had evacuated during Hurricane Irene, or reported pre-Sandy community cohesion. Evacuation was less likely among those who reported being prepared for an emergency. For evacuation timing, evacuation before Hurricane Sandy was less likely among those with pets and those who reported 14 or more poor physical health days.

Conclusions

Higher evacuation rates were observed for respondents seemingly more informed and who lived in neighborhoods with greater social capital. Improved disaster messaging that amplifies these factors may increase adherence with evacuation warnings. (Disaster Med Public Health Preparedness. 2016;10:411–419)

Exposure to the World Trade Center Disaster and 9/11-Related Post-Traumatic Stress Disorder and Household Disaster Preparedness

Objective

In a population with prior exposure to the World Trade Center disaster, this study sought to determine the subsequent level of preparedness for a new disaster and how preparedness varied with population characteristics that are both disaster-related and non-disaster-related.

Methods

The sample included 4496 World Trade Center Health Registry enrollees who completed the Wave 3 (2011-2012) and Hurricane Sandy (2013) surveys. Participants were considered prepared if they reported possessing at least 7 of 8 standard preparedness items. Logistic regression was used to determine associations between preparedness and demographic and medical factors, 9/11-related post-traumatic stress disorder (PTSD) assessed at Wave 3, 9/11 exposure, and social support.

Results

Over one-third (37.5%) of participants were prepared with 18.8% possessing all 8 items. The item most often missing was an evacuation plan (69.8%). Higher levels of social support were associated with being prepared. High levels of 9/11 exposure were associated with being prepared in both the PTSD and non-PTSD subgroups.

Conclusions

Our findings indicate that prior 9/11 exposure favorably impacted Hurricane Sandy preparedness. Future preparedness messaging should target people with low social support networks. Communications should include information on evacuation zones and where to find information about how to evacuate. (Disaster Med Public Health Preparedness. 2015;9:625–633)

Posttraumatic Stress Disorder after Hurricane Sandy among Persons Exposed to the 9/11 Disaster

BACKGROUND

Traumatic exposure during a hurricane is associated with adverse mental health conditions post-event. The World Trade Center Health Registry provided a sampling pool for a rapid survey of persons directly affected by Hurricane Sandy in the New York City (NYC) metropolitan area in late October 2012. This study evaluated the relationship between Sandy experiences and Sandy-related posttraumatic stress disorder (PTSD) among individuals previously exposed to the September 11, 2001 (9/11) disaster.

METHODS

A total of 4,558 surveys were completed from April 10-November 7, 2013. After exclusions for missing data, the final sample included 2,214 (53.5%) respondents from FEMA-defined inundation zones and 1,923 (46.5%) from non-inundation zones. Sandy exposures included witnessing terrible events, Sandy-related injury, fearing for own life or safety of others, evacuation, living in a home that was flooded or damaged, property loss, and financial loss. Sandy-related PTSD was defined as a score of ≥44 on a Sandy-specific PTSD Checklist.

RESULTS

PTSD prevalence was higher in the inundation zones (11.3%) and lower in the non-inundation zones (4.4%). The highest prevalence of Sandy-related PTSD was among individuals in the inundation zone who sustained an injury (31.2%), reported a history of 9/11-related PTSD (28.8%), or had low social support prior to the event (28.6%). In the inundation zones, significantly elevated adjusted odds of Sandy-related PTSD were observed among persons with a prior history of 9/11-related PTSD, low social support, and those who experienced a greater number of Sandy traumatic events.

CONCLUSIONS

Sandy-related stress symptoms indicative of PTSD affected a significant proportion of persons who lived in flooded areas of the NYC metropolitan area. Prior 9/11-related PTSD increased the likelihood of Sandy-related PTSD, while social support was protective. Public health preparation for events similar to Sandy should incorporate outreach and linkages to care for persons with prior disaster-related trauma.

Chronic probable PTSD in police responders in the world trade center health registry ten to eleven years after 9/11

BACKGROUND

Police enrolled in the World Trade Center Health Registry (WTCHR) demonstrated increased probable posttraumatic stress disorder (PTSD) after the terrorist attack of 9/11/2001.

METHODS

Police enrollees without pre-9/11 PTSD were studied. Probable PTSD was assessed by Posttraumatic Stress Check List (PCL). Risk factors for chronic, new onset or resolved PTSD were assessed using multinomial logistic regression.

RESULTS

Half of police with probable PTSD in 2003-2007 continued to have probable PTSD in 2011-2012. Women had higher prevalence of PTSD than men (15.5% vs. 10.3%, P = 0.008). Risk factors for chronic PTSD included decreased social support, unemployment, 2+ life stressors in last 12 months, 2+ life-threatening events since 9/11, 2+ injuries during the 9/11 attacks, and unmet mental health needs.

CONCLUSION

Police responders to the WTC attacks continue to bear a high mental health burden. Improved early access to mental health treatment for police exposed to disasters may be needed.

Fear and C-reactive protein cosynergize annual pulse increases in healthy adults

Recent international terror outbreaks notably involve long-term mental health risks to the exposed population, but whether physical health risks are also anticipated has remained unknown. Here, we report fear of terror-induced annual increases in resting heart rate (pulse), a notable risk factor of all-cause mortality. Partial least squares analysis based on 325 measured parameters successfully predicted annual pulse increases, inverse to the expected age-related pulse decline, in approximately 4.1% of a cohort of 17,380 apparently healthy active Israeli adults. Nonbiased hierarchical regression analysis among 27 of those parameters identified pertinent fear of terror combined with the inflammatory biomarker C-reactive protein as prominent coregulators of the observed annual pulse increases. In comparison, basal pulse primarily depended on general physiological parameters and reduced cholinergic control over anxiety and inflammation, together indicating that consistent exposure to terror threats ignites fear-induced exacerbation of preexisting neuro-immune risks of all-cause mortality.

Mass fatality preparedness among medical examiners/coroners in the United States: a cross-sectional study

Background

In the United States (US), Medical Examiners and Coroners (ME/Cs) have the legal authority for the management of mass fatality incidents (MFI). Yet, preparedness and operational capabilities in this sector remain largely unknown. The purpose of this study was twofold; first, to identify appropriate measures of preparedness, and second, to assess preparedness levels and factors significantly associated with preparedness.

Methods

Three separate checklists were developed to measure different aspects of preparedness: MFI Plan Elements, Operational Capabilities, and Pre-existing Resource Networks. Using a cross-sectional study design, data on these and other variables of interest were collected in 2014 from a national convenience sample of ME/C using an internet-based, anonymous survey. Preparedness levels were determined and compared across Federal Regions and in relation to the number of Presidential Disaster Declarations, also by Federal Region. Bivariate logistic and multivariable models estimated the associations between organizational characteristics and relative preparedness.

Results

A large proportion (42%) of respondents reported that less than 25 additional fatalities over a 48-hour period would exceed their response capacities. The preparedness constructs measured three related, yet distinct, aspects of preparedness, with scores highly variable and generally suboptimal. Median scores for the three preparedness measures also varied across Federal Regions and as compared to the number of Presidential Declared Disasters, also by Federal Region. Capacity was especially limited for activating missing persons call centers, launching public communications, especially via social media, and identifying temporary interment sites. The provision of staff training was the only factor studied that was significantly (positively) associated (p < .05) with all three preparedness measures. Although ME/Cs ranked local partners, such as Offices of Emergency Management, first responders, and funeral homes, as the most important sources of assistance, a sizeable proportion (72%) expected federal assistance.

Conclusions

The three measures of MFI preparedness allowed for a broad and comprehensive assessment of preparedness. In the future, these measures can serve as useful benchmarks or criteria for assessing ME/Cs preparedness. The study findings suggest multiple opportunities for improvement, including the development and implementation of national strategies to ensure uniform standards for MFI management across all jurisdictions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1275) contains supplementary material, which is available to authorized users.