Risk factors for persistence of lower respiratory symptoms among community members exposed to the 2001 World Trade Center terrorist attacks

Occup Environ Med. 2017 Jun;74(6):449-455. doi: 10.1136/oemed-2016-104157. Epub 2017 Mar 24.


Objectives: We studied the course of lower respiratory symptoms (LRS; cough, wheeze or dyspnoea) among community members exposed to the 9/11/2001 World Trade Center (WTC) attacks during a period of 12-13 years following the attacks, and evaluated risk factors for LRS persistence, including peripheral airway dysfunction and post-traumatic stress disorder (PTSD).

Methods: Non-smoking adult participants in a case-control study of post-9/11-onset LRS (exam 1, 2008-2010) were recruited for follow-up (exam 2, 2013-2014). Peripheral airway function was assessed with impulse oscillometry measures of R5 and R5-20. Probable PTSD was a PTSD checklist score 44 on a 2006-2007 questionnaire.

Results: Of 785 exam 1 participants, 545 (69%) completed exam 2. Most (321, 59%) were asymptomatic at all assessments. Among 192 participants with initial LRS, symptoms resolved for 110 (57%) by exam 2, 55 (29%) had persistent LRS and 27 (14%) had other patterns. The proportion with normal spirometry increased from 65% at exam 1 to 85% at exam 2 in the persistent LRS group (p<0.01) and was stable among asymptomatic participants and those with resolved LRS. By exam 2, spirometry results did not differ across symptom groups; however, R5 and R5-20 abnormalities were more common among participants with persistent LRS (56% and 46%, respectively) than among participants with resolved LRS (30%, p<0.01; 27%, p=0.03) or asymptomatic participants (20%, p<0.001; 8.2%, p<0.001). PTSD, R5 at exam 1, and R5-20 at exam 1 were each independently associated with persistent LRS.

Conclusions: Peripheral airway dysfunction and PTSD may contribute to LRS persistence. Assessment of peripheral airway function detected pulmonary damage not evident on spirometry. Mental and physical healthcare for survivors of complex environmental disasters should be coordinated carefully.

Keywords: Environmental Exposure; Lung Function Tests; Signs and Symptoms, Respiratory.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Air Pollutants / adverse effects*
  • Air Pollutants / analysis
  • Air Pollution / adverse effects
  • Case-Control Studies
  • Cough
  • Dyspnea
  • Environmental Exposure / adverse effects*
  • Environmental Exposure / analysis
  • Female
  • Forced Expiratory Volume
  • Humans
  • Male
  • Middle Aged
  • New York City / epidemiology
  • Oscillometry
  • Registries
  • Respiration Disorders / epidemiology*
  • Respiration Disorders / etiology*
  • Respiration Disorders / psychology
  • Respiratory Sounds
  • Risk Factors
  • September 11 Terrorist Attacks
  • Stress Disorders, Post-Traumatic / epidemiology*
  • Stress Disorders, Post-Traumatic / etiology*
  • Stress Disorders, Post-Traumatic / psychology
  • Surveys and Questionnaires
  • Terrorism
  • Young Adult


  • Air Pollutants