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Children’s Health After 9/11: The Physical Effects

Dr. Sandro Cinti is Clinical Associate Professor of Internal Medicine and Infectious Diseases at the University of Michigan Medical School and the Veteran’s Affairs Ann Arbor Health System. A specialist in infectious diseases, he has had a long-standing involvement in preparations at the national, state and local level for responding to biodisasters such as pandemic influenza and bioterrorism.

I am going to talk about is the physical health of children affected by 9/11.

The fact of the matter as we all know is that children are very versatile.  Children heal well. That’s why it’s no accident that I’m a panel of one. I called people at Mount Sinai, I called people at Columbia, and they said, we’d love to come but there isn’t anything to say. I was given some literature on the physical health of children and the things that can occur in a situation like the aftermath of 9/11, such as exposure to the potential irritants that were released when the buildings came down. I talked to another of the speakers here who was several miles away and he said paper was falling in that part of the city, paper from the offices all that distance away. You had all those irritants, wood, concrete, plastic, paper, alkaline dust, dust clouds containing heavy metals. You can imagine all this stuff, all this equipment in these huge buildings, the biggest buildings in the world, melting, and then being part of a big mass of gas and dust that is flowing outward.

So, as to the physical effects: an immediate effect of the dust is reactive airway disease. Then there are reactions that occur later, diseases such as inflammatory lung disease or sarcoidosis. The lungs over time degenerate and the immune response turns on the patient’s own body and causes a continued inflammatory state. Luckily, children don’t have a lot of these long-lasting problems.  They heal well.  They do have problems with asthma but some of these other illnesses they just don’t get.

So kids do pretty well, but I will talk about a few of the aspects here. For example, indoor dust is more dangerous — I didn’t know this but it is protected from rain, so it retains its alkalinity. Dust indoors has a higher alkalinity than anything on the outside because rain washes those substances off, and alkalinity can cause a lot more damage.  Smoke and other gaseous materials can also cause problems. You have asbestos, you have lead, volatile organic compounds, dioxins. They cause problems by inhalation, or by transdermal absorption.

There are some longer-term effects that include cancer — we probably still don’t know the incidence.  Are we going to suddenly start seeing kids who were born at that time, or who were young at that time, developing unusual cancers, particularly lung cancer (e.g. mesotheliomas, from asbestos exposure)? That still may be down the line.

The post-9/11 physical health effects in adults, particularly fire fighters and police, are clear. These include asthma, rhinitis and sinusitis, gastroesophageal reflux disease (GERD), and other pulmonary diseases including sarcoidosis and interstitial fibrosis. It’s less clear but there is a potential for future cancers. But effects in adults  don’t necessarily reflect what you’ll find in children. How do you assess children who were exposed, or potentially exposed?

Although as you know children heal well, there are certain problems.  Their living zones and their breathing zones are closer to the ground, so when there is exposure to things that are heavy — gases that are heavy, metals that are heavy — adults are going to have less problems with those.  Kids spend more time in a single place, so if that place happens to have a high concentration of poisons the child is going to be more susceptible.  Children consume more food and water per unit of weight and so they may ingest more toxin if that happens to be in the environment. Their skin has a greater surface relative to body volume, which leads to increased absorption through the skin if there are toxins in the air. You can think of kids as being sponges that are much more absorbent than adults, and so they might get higher doses of poisons in their body. Again, you have to take that with the other side, the reasons that kids do remarkably well. Their kidneys work better than ours, their livers work better than ours, and these are the organs that eventually clear these poisons.

The World Trade Center Health Registry looked at 3,184 kids who were less than 18 years old on 9/11 and they studied these kids for two to three years. [1] Two to three years afterwards they looked at five-year-olds because it appeared that kids five years and younger really were at higher risk than older kids. They found that kids five years and under had twice as much newly diagnosed asthma as the same age kids on an average in other parts of the northeast United States. Kids older than that did not have as many problems.  One thing about kids is that they are small, so they have small airways too. Because their airways are smaller a minor inflammatory response may cause increased symptoms in a kid that age. So they may just present to the physicians more.

The children at the sites also had a higher rates of sinus problems and heartburn.  The heartburn may be related to stress. The sinus problems make sense because again that’s an airway associated problem.

You have to be aware that a lot of these results are based on questionnaires.  They are not actually testing all these kids for asthma; they are asking the parents, reporting parents saying yes or no on whether the kids have asthma or not.  In some cases they may think their kid has asthma, but the doctor may not think so.  So you have to take some of this with a grain of salt, but these were large studies. They looked at more than 3,000 kids.  And there is some other evidence, such as a study of children in Chinatown that also showed a greater increase in asthma after 9/11 among those children who were closer to the site.

Finally, there are some studies that have looked at women who were pregnant at the time and were exposed to conditions after the 9/11 disaster. These are smaller studies because they could not capture a lot of women who were pregnant at the time of 9/11 and who were in the area.  It was really difficult to find these women.  They sent out fliers to OB-GYNs, they put out requests in newspapers to try and find those patients. Some results, but not all, showed that post-9/11 exposure did have an association with lower birth weight, intrauterine growth restriction and shorter length at delivery.

The good news is that not all those adverse effects showed up in the largest of those studies. [2] That study had a sample of 187 women; women who were pregnant and were in one of the five zones that were considered to have high rates of exposure. The women had been in those high exposure zones within three weeks of the 9/11 attacks  They were compared to 2,300 pregnant women on the upper East Side who never were in these zones at any point. The World Trade Center cohort had a twofold increase in intrauterine growth restriction. An intrauterine growth restriction is when they measure the size of the baby as it goes through gestation.  Interestingly, there was no difference in the mean birth weight, so these babies ended up at some point in utero catching up to be the same weight. So maybe it didn’t really matter that much.  There was no increased in preterm birth, no increase in low birth rate, no differences in mean birth weight, or mean gestational age.  They were all born essentially when they should have been born.

There can be problems with some of these studies. A sample of 187 is not that many; 187 women do not a prospective randomized control study make. And when you compare a group that had an exposure to a control group, those two groups should be the same in every way except the exposure, but unfortunately they could not achieve that in this one study because the women who were in those exposure zones were older, 34.6 years old on average, compared to 32.4 in the control group. That may not look like a significant gap in age, but for the study purposes it’s considered a significant difference. Maybe it did make some difference in the results, or somebody might criticize the study and say it is not because they were exposed that these kids had more problems, it is because these women were older.

So there is that question about this particular study, but in general, it seems to be good news. There were some problems but it looks to me like these women generally had pretty healthy babies. Even though there was the one finding that there was increased risk of intrauterine growth restriction, it did not register as a difference when the kids were born. When the babies were eventually born they did fine.


[1]

* See Thomas PA, Brackbill R, Thalji L, et al. Respiratory and other health effects reported in children exposed to the World Trade Center disaster of 11 September 2001. Environ Health Perspect. 2008;116(10): 1383-1390. Available online at http://ehp03.niehs.nih.gov/article/fetchArticle.action;jsessionid=493F752891CF43CABA69EB3B299025D1?articleURI=info%3Adoi%2F10.1289%2Fehp.11205

See also City Health Information, July 2009 The NewYork City Department of Health and Mental Hygiene Vol. 28(4):29-40; http://www.nyc.gov/html/doh/downloads/pdf/chi/chi28-4.pdf

The World Trade Center (WTC) Health Registry  (http://www.nyc.gov/html/doh/wtc/html/registry/registry.shtml) was established in 2002 by the federal Agency for Toxic Substances and Disease Registry and the New York City Health Department to monitor the health of people directly exposed to the WTC disaster. In collaboration with the National Institute for Occupational Safety and Health, the WTC Health Registry plans a long-term follow-up, tracking changes in physical and mental health in that population over the next 20 years.

[2]

Berkowitz GS, Wolff MS, Janevic TM, Holzman IR,Yehuda R, Landrigan PJ. The World Trade Center disaster and intrauterine growth restriction. JAMA. 2003;290(5):595-596.

See also Lederman SA, Rauh V,Weiss L, et al. The effects of the World Trade Center event on birth outcomes among term deliveries at three Lower Manhattan hospitals. Environ Health Perspect. 2004;112(4):1772-1778, and Eskenazi B, Marks AR, Catalano R, Bruckner T, Toniolo PG. Low birthweight in New York City and upstate New York following the events of September 11th. Hum Reprod. 2007;22(11):3013-3020