April 27, 2004 -- The legacy of the 2001 anthrax attacks lives on in the minds of millions. But for a small group of Americans who survived exposure to the deadly bacteria, the effects of the bioterrorist attacks also continue to plague their bodies.
A new study shows 15 people infected with anthrax during the attacks continue to report significant health problems, psychological distress, and trouble readjusting to life at least a year after the terrorist attacks involving the U.S. Postal Service in the fall of 2001.
Researchers found that more than half of the victims had not returned to work more than a year after the attacks, all were under psychiatric care, and most reported symptoms ranging from chronic cough, fatigue, and memory problems to depression, anxiety, and hostility.
The findings appear in the April 28 issue of The Journal of the American Medical Association.
First Look at Long-Term Effects of Bioterrorism
Researcher Dori Reissman, MD, MPH, senior advisor for emergency preparedness and mental health at the CDC, says the study is the first to look at the long-term effects of bioterrorism-related anthrax infection and suggests that the psychological impact of the exposure may be as significant as the physical effects of the disease.
The study involved 15 of the 16 adult anthrax survivors from September to December 2002, approximately one year after they were infected as a result of the bioterrorist attacks. Six survivors had the more serious inhalational anthrax caused by inhaling the anthrax spores, and 11 had cutaneous anthrax, caused by skin contact with the anthrax bacteria.
The survivors were interviewed about their health complaints and completed two standardized questionnaires about their psychological symptoms and health-related quality of life. Researchers also reviewed available medical records to check for evidence of some of the most commonly reported health problems.
The results showed that the anthrax survivors reported moderate to severe symptoms affecting many body systems. Eight of the survivors had not returned to work since their infection.
The most commonly reported health complaints included:
The most frequently cited symptoms of psychological distress were:
The researchers noted that medical tests often could not pinpoint the cause of their complaints.
For example, eight survivors reported moderate to severe joint problems, decreased physical functioning, and prolonged work absence. But 11 diagnostic tests, including X-rays and lab tests, performed on six of these patients showed no signs of immune or inflammatory disorders or other common medical explanations for these symptoms.
Reissman says those findings suggest that posttraumatic stress disorder (PTSD) may be responsible for some of the physical as well as psychological symptoms.
"Since we were not able to link from a causal point of view the ongoing health problems with the anthrax infection or the toxins released by the bacteria, we're left with the traumatic situation," says Reissman.
Luciana Borio, MD, senior fellow at the Center for Biosecurity at the University of Pittsburgh Medical Center, says it's not unusual for PTSD in the wake of a terrorist event to cause a variety of physical symptoms, the cause of which cannot always be determined through conventional medical testing.
"The way people perceive physical symptoms sometimes is difficult to measure and may be due to psychosocial distress," Borio tells WebMD. "These symptoms seem more consistent with PTSD -- not because they're not there, but because we can't measure it."
As further evidence that the symptoms may have a psychological basis, the study showed that the severity of the complaints among the victims was nearly the same between the inhalational and cutaneous anthrax survivors except in the areas of physical and social functioning. In those measures, inhalational anthrax survivors tended to suffer more due to the severity of their disease.
Bioterrorist Attacks Cause More Than Disease
To put their results into context, researchers compared their findings to studies on long-term survivors of other infectious diseases and persons with chronic health conditions because there is so little information on the long-term effects of anthrax.
In comparison, anthrax survivors had a harder time adjusting to life after infection and fared far worse than persons with chronic illness on most measures, such as physical functioning, bodily pain, and mental health.
Borio says she's not surprised that the anthrax survivors report feeling distressed. While working at the National Institutes of Health, she published a detailed account of the medical treatment of two Washington, D.C. postal workers who eventually died from inhalational anthrax.
She says not only is exposure to a bioterrorist attack traumatic, but the aggressive measures required to treat anthrax may also be traumatic. Treatment of the cutaneous or skin form of anthrax usually involves taking powerful antibiotics to kill and prevent further spread of the infection.
But once the bacteria has spread to the lungs, as in the inhaled form of anthrax, infected patients may require assistance to breathe and repeated drainage of fluid in the lungs, which Borio says is not a painless procedure.
"The [inhaled form of the] disease is much scarier because it is a systemic disease," Borio tells WebMD. "People may feel that they have survived it, and they were not supposed to have survived because historically the death rates were so high, and they all required very aggressive medical care."
In addition to the mental stress most Americans feel in the wake of the bioterrorist attacks of 2001, Borio says anthrax survivors must deal with a much more personal threat.
"The stress of living under the threat of terrorism may play a part because it is not removed once you get better," says Borio. "What made you sick back then can come back again and make you sick again. That ought to be stressful."
Reissman says the findings suggest that the psychological impact of the bioterrorist attacks may deserve more attention from health care providers rather than just the immediate physical effects.
"In the follow-up of these kinds of events," says Reissman, "It's very, very important for us to be including the functional, psychological, and behavioral response to them as a standard practice."
But Reissman says the study also suggests there is something that health care providers can do to lessen the impact of bioterrorist attacks. Potential interventions may include medications for specific PTSD-related symptoms as well as psychotherapy.
"There is a lot of good hope in terms of intervening with these individuals and returning them to a good quality of life," says Reissman.