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Sean Clouston

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These composite brain images from the study of WTC responders reveal evidence of amyloidosis. Areas shaded in red and yellow indicate regions of the brain with amyloid. Image courtesy of Sean Clouston, Stony Brook Medicine

By Daniel Dunaief

Even over 23 years after first responders raced to the smoldering site of the World Trade Center terrorist attacks, many emergency crews continue to battle the effects of their exposure.

With a combination of toxic aerosolized particles infusing the air, first responders who didn’t wear personal protective equipment and who had the highest degree of exposure have suffered from a range of symptoms and conditions.

Sean Clouston

In a recent study of 35 World Trade Center first responders in the Journal of Alzheimer’s Disease, lead author Sean Clouston, who is a Professor in the Department of Family, Population and Preventive Medicine in the Renaissance School of Medicine, found evidence of amyloid plaques, which are often linked to Alzheimer’s Disease.

The paper links exposure to a neurodegenerative protein.

Research with World Trade Center first responders not only benefits those who worked tirelessly to try to find survivors and to restore the area after the attack, but also could help other people who inhale aerosolized toxins.

Indeed, such research could help those who are spending hours battling the ongoing wildfires in Los Angeles, which have been consuming forests and trees, homes and commercial buildings, at a furious and uncontrolled pace.

People have a feeling that fresh air is safe, but what scientists have learned from their studies of the World Trade Center first responders is that “just being six feet away from a pile of rubble that’s smoldering, even if you can’t see that it’s dangerous, doesn’t mean it isn’t,” said Clouston. “There is at least some risk” to human health from fires that spew smoke from burned computers and refrigerators, among others.

Given the variety of materials burned in the fires, Minos Kritikos, Senior Research Scientist and a member of the group in the collaborative labs of Clouston and Professor Benjamin Luft, suspects that a heterogeneity of particles were in the air.

People in Los Angeles who are inhaling these particles can have them “linger in their circulation for years,” said Kritikos. “It’s not just a neurological issue” as the body tries to deal with carrying around this “noxious” particulate matter. Since most neurons don’t regenerate, any toxicity induced neuronal death is irreversible, making damage to the brain permanent.

Even in non-emergency situations, people in polluted cities face increased health risks.

“There is a recognition that air pollution is a major preventable cause of Alzheimer’s Disease and related dementias, as noted by the latest Lancet Commission,” Clouston explained.

Two likely entry points

People who breathe in air containing toxic chemicals have two likely pathways through which the particulates enter the body. They can come in through the nose and, potentially, travel directly into the brain, or they can enter the lungs, circulate through the body and enter the head through the blood-brain barrier. The olfactory route is more direct, said Kritikos. 

Minos Kritikos in front of Stony Brook Hospital.

The amyloid plaques in these first responders was found primarily in the area near the nose, which supports the idea that maybe inhaling the dust was the problem, Clouston said.

Once these chemicals enter the brain, Clouston and his team believe the body engages defenses that are designed much more for viruses than for toxic compounds. The immune system can encapsulate these chemicals in amyloid plaques.

Amyloid plaques, in moderation and under conditions that protect the brain against pathogens, are a part of a protective and helpful immune response. Too much of a good thing, however, can overwhelm the brain.

“When there’s too much plaque, it can physically disturb neuronal functions and connections,” said Kritikos. “By being a big presence, they can also molecularly and chemically react with its environment.”

A large presence of amyloid can be toxically necrotic to surrounding neural tissue, Kritikos added.

What the scientists believe they are tracking is the footprint of an adaptive response that may not help the brain, Clouston added.

Clouston cautioned that the plaques and cognitive decline could both be caused by something else that scientists haven’t yet seen.

The findings

The research, which used positron emission tomography and magnetic resonance imaging scans to search for evidence of amyloid plaques, found evidence that doesn’t look like old age Alzheimer’s, explained Clouston. Usually these levels of plaques are not located in one spot, but occur throughout the brain during Alzheimer’s. 

The immune response may be causing some of these plaques.

The amount of amyloid plaque doesn’t look like Alzheimer’s Disease and does not appear abnormal in the traditional way of testing, but with careful analysis of the olfactory system, the researchers can find elevated levels.

“I was surprised by how little amyloid was necessary to show this association,” said Clouston.

Researchers at Mt. Sinai have examined the effect of exposure to these same particulates in mice.

“The answer is very much similar to what we see in humans,” said Clouston. “That supports this work.”

To be sure, Clouston and Kritikos are hoping to build on this research. They are particularly interested in following up with participants to measure the rate of change in these plaques from the observed amyloid signals they measured at baseline.

“Doing so would enable us to calculate the rate of amyloid buildup allowing us to assess our responders more precisely, opening doors to possible therapeutic interventions such as the recently approved anti-amyloid therapies,” Kritikos explained. 

Additionally, they hope to expand on the study beyond the 35 people who participated.

It is unclear whether tamping down the immune system could make patients better or worse. By reducing amyloid plaques, scientists might enable the harmful dust to cause damage in other areas of the brain. Alternatively, however, a lower level immune response with fewer plaques might, in the longer term, be better for the brain.

This study “does open the door for some of those questions,” Clouston said. Kritikos and Clouston plan to study the presence of tau proteins and any signs of neurodegeneration in the brains of these first responders.

“More research needs to be done,” Clouston said, which specifically targets different ways of measuring exposure, such as through a biomarker. He’s hoping such a biomarker might be found that tracks levels of exposure.

Future research could also address whether post traumatic stress disorder affects the immune response.

“It’s certainly possible that PTSD is playing a role, but we’re not sure what that might be,” said Clouston.

The researchers are continuing this research as they study the effects of exposure on tau proteins and neurodegeneration.

“We are hopeful that this will be an important turning point for us,” Clouston explained

From the Medditerranean to the Atlantic

Born and raised in Cyprus, Kritikos comes from a large family who are passionate about spending time with each other while eating good food.

He earned his doctorate from the University of Bristol in England.

Kritikos met his wife Jennifer LoPresti Kritikos, who is originally from Shirley, New York, at a coffee shop in Aberdeen, Scotland, where he was doing postdoctoral research.

LoPresti, who works at Stony Brook as the Department Head Administrator for Biomedical Engineering, and Kritikos live in Manorville and have an eight year-old daughter Gia and one-year old son Theseus.

As for his work, Kritikos is grateful for the opportunity to contribute to research with Clouston and Luft, who is the Director of the Stony Brook WTC Health and Wellness Program.

“I’m happy to be in a position whereby our large WTC team (the size of a small village) is constantly pushing forward with our understanding for how these exposures have affected” the brain health of WTC first responders, Kritikos explained. He would like to continue to uncover mechanisms that underly these phenomena, not just for WTC responders but also for similarly exposed populations.

 

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Individuals who have had multiple Covid-19 infections appear prone to contracting Long Covid, which may include symptoms such as fatigue, respiratory distress and mental fog.

Study published in The Lancet provides a basis for investigating Long Covid in the post-pandemic era

A new study that identified 475 patients with post-acute sequelae of Covid-19 (PASC), also known as Long Covid, revealed that nearly 85 percent (403) of these patients had multiple Covid-19 infections over the course of a four-year period (March 2020 to February 2024). Additionally, vaccination independently reduced the risk of Long Covid in patients who had received the vaccination prior to contracting the infection.

Conducted by a team of researchers at the Renaissance School of Medicine (RSOM) at Stony Brook University, in conjunction with the Stony Brook World Trade Center (WTC) Health and Wellness Program, the study may serve as a foundational assessment of Long Covid patients in the post-pandemic era. To date there are few studies with such a patient sample size that investigates what puts patients at risk for Long Covid and what causes this chronic condition.

The findings are published early online in the February edition of The Lancet Regional Health – Americas.

“While it is possible that the causes of Long Covid could be many and variable depending on the patient population studied, with this cohort the evidence is clear that by having Covid numerous times, patients became more at-risk for developing Long Covid,” says lead author Sean Clouston, PhD, Professor, Department of Family, Population and Preventive Medicine in the RSOM, and Program in Public Health.

He adds that after adjusting for relevant demographic, lifestyle, and clinical variables, the findings reveal a statistically significant association between experiencing multiple Covid-19 infections and the risk of experiencing PASC (aka Long Covid).

The patients were identified from a group of more than 2,500 first responders who previously had Covid and are prospectively monitored for infection complications by the Stony Brook WTC Health and Wellness Program. The 475 identified with Long Covid by the Program’s physicians, led by Benjamin Luft, MD, Director of the Program, continually experienced Long Covid symptoms ranging from fatigue, mental fog, other neurological conditions, as well as multiple respiratory problems and gastrointestinal symptoms.

Given that some of the first responder patients have had symptoms over the years related to their environmental exposures, such as respiratory illnesses, Long Covid symptoms were identified and charted separately and after each subsequent Covid infection.

Since there is no diagnostic test for Long Covid, the researchers followed the World Health Organization’s guidelines as to identifying Long Covid. They identified participants with Long Covid as having experienced the continuation or development of at least one new symptom that emerged within three months after their initial Covid-19 infection and persisted for at least two months without other concurrent medical explanation. In contrast, those without such experiences after having Covid were placed in the non-Long Covid group.

“There are some possible pathogenic mechanisms that cause Long Covid, but the entire spectrum of its risk factors remains unknown,” explains Dr. Luft, a co-author, the Edmund D. Pellegrino Professor of Medicine in the RSOM, and an infectious diseases specialist. “This is why our study and future ones are so important. Identifying specific risk factors such as re-infection or lack of vaccination can assist in better understanding and managing the condition.”

The authors point out that the safest way to avoid contracting Long covid is to prevent the infection in the first place. However, they emphasize that the role of vaccination in the risk of developing Long Covid cannot be underestimated. They wrote, “Among those who later developed PASC, we found that the risk of PASC was much higher among individuals who were unvaccinated at the time of their first (Covid-19) infection.”

Dr. Luft adds that the vaccine is imperfect, and of those who develop Covid – even though vaccinated – are at risk and should take measures to mitigate the severity of infection.

This research was supported in part by the National Institutes of Health’s National Institute on Aging (NIA) and National Institute for Occupational Safety and Health (NIOSH) – grants (NIH/NIA R01 AG049953), and the Centers for Disease Control and Prevention – grants (CDC/NIOSH U01 OH011864) and (CDC/NIOSH U01 OH012275).

 

 

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World Trade Center worker. Photo courtesy Steven Spak

By Daniel Dunaief

Sean Clouston takes some time to reflect each year around this time.

Sean Clouston

 

A professor in the Department of Family, Population and Preventive Medicine in the Program in Public Health at Stony Brook University, Clouston studies the long term implications of the exposure and experiences of first responders after the attacks on the World Trade Center.

Clouston, who published research this summer that chronicled the higher rates of dementia among first responders in the years after the attack, spoke exclusively with the Times Beacon Record Newspapers about the work he does and the interactions he’s had with people who were in harm’s way in the days and weeks after the terrorist attacks.

Each September 11th is a “quiet day,” Clouston said, as he takes time to remember those lost  and reflect on those who are continuing to deal with the health consequences of being there.

Clouston recalls thinking about how the attacks shaped the way he thought about what he should be doing with his life.

In the work he’s done in monitoring the role of long-duration exposures at the World Trade Center on neurological health of responders to the events following the Sept. 11 attacks, Clouston has interacted with survivors, spouses, and families, receiving regular updates.

“It’s a pretty big part of my everyday social network,” Clouston said.

He’s heard numerous stories from a day in which the comfortable, clear air provided an incongruous backdrop for the mass murders. He has heard about people who were blown out of the buiding amid a combustible blast and about how difficult it is to put out a cesium fire.

“There were definitelly so many different stories that speak to me,” Clouston said.

As someone who studies the outcomes of severe or early life challenges, Clouston is aware of how the traumatic events of that day reoccur for so many people, as they reexperience the moments that sometimes haunt their dreams and that can continue to affect them physically and cognitively.

People generally consider post traumatic stress as a “fairly short condition” where someone has it “immediately after an event and it kind of goes away,” Clouston said.

For first responders, however, “that’s not true. They are dealing with it for years or decades after the traumatic event.”

Indeed, first responders not only feel the effects of the physical and emotional trauma, but the experience affects their body chemistry and “changes how their immune system reacts.”

Researchers can see how it “wears away at the body over the years and over the decades,’ Clouston added.

The study of post traumatic stress allows him to focus on and understand the link between the mind and the body.

How can people help?

Clouston suggested that people who want to help first responders need to start by recognizing the specific challenges each person may be facing.

“What you do depends a lot on who the person is and what they remember and what they’re struggling with,” said Clouston.

Sept. 11th each year can be a hard time, as people confront painful memories.

People can help others by “being available to listen,” he suggested. Try to understand “why it affects them and how.”

Therapists can help, as can doctor-prescribed medications.

First responders may feel angry, which people don’t always anticipate feeling.

In his research, Clouston focuses less on day-to-day changes and more on how their exposure and experience affects them in the longer term.

First responders can become physically weaker and slower, as they are less able to lift weights.

Cognitively, the effect of the experience has also been significant.

Earlier this year, Clouston published a paper in which he found an “enormous difference” between people with minimal exposure to dust and other particulates at the World Trade Center site compared to those who were more heavily exposed, he said.

“The incidence of dementia is building on prior work showing that the longer you were on site, the more likely responders were to have slowed down cognitive function in general,” he added.

Future questions

Clouston and his colleagues are hoping to understand what disease is affecting first responders. They are unsure whether it’s a form of dementia related to other conditions or whether it’s unique to this group and this exposure.

They are hoping to explore whether people who were on site have anything in their blood that is a measure of exposure, such as chemicals or metals.

First responders don’t all need care now, but one of the goals of the research is to make sure scientists and doctors are “on top of what is really happening” as they prepare to provide any necessary help in future years.

People develop diseases when three things occur: a noxious or toxic element or viral particle exists, they are exposed to it, and people are vulnerable to its effects.

Researchers are working to understand the level of exposure and different levels of vulnerability.

Clouston also highlighted the connection between the immune system and tau proteins, which can trigger dementia in Alzheimer’s and which can spread throughout the brain.

Researchers have been exploring how some immune systems might spread these proteins, while other immune systems trigger a slower spread and, potentially, fewer and less severe symptoms.

In theory, scientists could learn from the immune system that causes a slower spread, although “we’re years away from doing anything like that,” he said.

Alternatiely, researchers and pharmaceutical companies are working on ways to remove these proteins.

“You can fight fires in two ways,” he said.

Stony Brook has been considering “those ideas. To get there, we have to first understand excatly where are we and what is the problem,” he said. “That’s where we really are for the next couple of years.”

As for his interaction with first responders, Clouston has been inspired by the way the first responder community has rallied around people who are struggling with physical and cognitive challenges.

He recalled a firefighter who was struggling with age-related conditions.

“His fellow firefighters came together and built in some lifts and ramps to help him and his spouse get around the house and use the bathroom,” he said. “Moments like that are really touching.”

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World Trade Center worker. Photo courtesy Steven Spak

By Daniel Dunaief 

First responders who raced to the World Trade Center site on 9/11 or who helped with the massive clean up effort did so at risk to themselves.

That was as true during those days and weeks after the attack as it is now, with many of the first responders experiencing a range of diseases and conditions linked to the difficult work they did in 2001.

In a study released recently in the journal JAMA Network Open, Sean Clouston, Professor in the Program in Public Health and in the Department of Family, Population and Preventive Medicine in the Renaissance School of Medicine at Stony Brook University, showed that 4.6 percent of the responders in a study developed dementia. That compares with 0.5 percent for the general population of people who would develop cognitive declines in a similar age group.

Between November of 2014 and January of 2023, 228 responders without dementia and under 60 years old at the start of the study developed dementia over the next five years.

“It’s stunning to see these kinds of symptoms in such young people,” said Clouston.

Through the Stony Brook WTC Health and Wellness Program, Clouston and other researchers have documented some of the cognitive declines in this population, who likely inhaled the kinds of fine particulate matter that can enter the brain and cause damage even as the immune system fights to try to target the unwelcome contaminants.

“We assume this made it in the brain, but in such a way that it wasn’t overwhelming immediately,” said Clouston. “Once you get into a neurodegenerative space, most of these diseases take a long time to develop” with neurodegenerative processes sometimes taking decades to occur.

The exposure could have caused an immune reaction. They are not sure whether symptoms emerged because the reaction was stronger or if the symptoms developed because higher exposure triggered a stronger reaction.

“It’s like trying to fight a fire, and the truck rolls over a garden to do it,” said Clouston.

Fortunately, the brain has considerable redundancy, which makes it possible to reroute brain signals to compensate for problems. Over time, however, that ability might be damaged by that work or by the exposure.

Determining which particular chemical or chemicals causes the greatest damage is difficult, particularly because the collapse and burning of the buildings caused a heterogeneous mixture of so many industrial products to enter the air. It may not matter much, as any material in the brain could be a problem. The type of exposure may also affect the severity of the immune reaction or which parts of the brain are damaged.

Scientists suggest that some of the contaminants that have contributed to health defects may come from the various tools in offices, such as computers and air conditioners.

“As we go forward [with other studies], that will be a focus of ours, to see if we can’t isolate at least one or maybe a couple” of chemicals that could exacerbate the cognitive decline, Clouston said.

Different exposures

Clouston and his collaborators used surveys to find out exposure at the site.

Some of the first responders, for example, used face masks and wore personal protective equipment, including hazmat suits. The incidence of dementia among that group was considerably lower than it was for those who didn’t wear masks.

Five or six out of every 1,000 workers who wore PPE developed dementia, while those without protection developed cognitive decline at the much higher rate of 42 out of 1,000.

The researchers tried to address the possibility that those people who were masks lived a healthier lifestyle prior to 9/11 and may have already been less likely to develop diseases or health conditions.

“We tried to account for that,” Clouston said. In most cases, people aren’t avoiding the kinds of activities or decisions that likely contribute to dementia, such as diet and exercise, which, the general population “widely ignores already,” he said.

Additionally, while a family history of dementia or other medical conditions mattered to some degree for the reported cases, they weren’t sufficient to invalidate the statistically significant result.

To be sure, Clouston acknowledged that the study could have a screening bias, as cognitive evaluations every 18 months likely far exceeds how often most people in the same age group receive testing for their mental acuity.

This is one reason they developed a minimally exposed group that could account for that bias. In that group, dementia was close to, but still higher than the expected rates for the general population.

The number of first responders with dementia far exceeded this group.

Other health threats

Medical professionals have been studying the impacts of other events that release aerosolized particles that could be hazardous to people’s health and could damage the environment.

Burn pits, which the military used in Iraq and Afghanistan, among other locations, contributed to cancers and other diseases among members of the military serving overseas.

Natural disasters, such as the Maui fire last August that not only burned through forests but also destroyed commercial buildings, also create a hazard.

People fled the fire quickly and then returned to search for their loved ones, Clouston said, which exposed them to aerosolized dust.

It would be “good to think about studies to consider risk of dementia” from these events, he added. 

“These studies would probably take a while to complete as the risk grows with time and with age.”

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Pixabay photo

By Daniel Dunaief

[email protected]

The number of people battling significant symptoms from the flu and respiratory syncytial virus has been coming down since its peak in January, as these infections have run their course.

“This year, we experienced the most severe flu and RSV waves in decades, and our COVID wave wasn’t small either,” said Sean Clouston, associate professor of Public Health at Stony Brook University.

The number of these illnesses was high as people no longer wore masks in places like schools and after people experienced lower-than-usual illnesses in the months before the mask mandate was lifted, creating fertile ground for viruses to spread.

“The most likely reason that the current flu and RSV seasons have improved is that we have had such a bad season earlier on that we have hit a natural ceiling on the ability for these diseases to successfully infect more people,” Clouston said in an email.

As for COVID-19, the numbers of people who have developed significant illnesses has continued to decline as well, through a combination of the natural immunity people have after their bodies successfully fought off the infection and from the protection offered by the vaccine and boosters.

Doctors added that the vaccine and natural immunity hasn’t prevented people from getting infected, but they have helped people avoid severe and potentially life-threatening symptoms.

“All these people who run around saying, ‘My vaccine isn’t working because I got reinfected,’ are missing the point,” said Dr. Bettina Fries, chief of the Division of Infectious Diseases at Stony Brook Medicine. “It is working. It doesn’t protect you from infection, but [it does prevent] a bad outcome.”

Indeed, during the most recent COVID surge during the winter, Fries said the hospital continued to care for patients, most of whom recovered. 

Vaccine timing

Amid discussions from the Centers for Disease Control and Prevention and health organizations throughout the state and country about the timing of future booster shots, local health care providers indicated the increasing likelihood of an annual COVID booster.

Fries said we will get to an annual vaccination for COVID, adding, “It’s the same as we see with the flu.”

In general, people aren’t rushing off to get an updated COVID booster.

“To maximize the protective value of the vaccine while minimizing the number of vaccines you use, people should likely get the vaccine two weeks before they anticipate heavy exposure,” Clouston said.

For most people, that would mean getting the shot in early November to prepare for larger indoor gatherings, like Thanksgiving and the December holidays.

In a recent article in the journal Lancet, researchers conducted an extensive analysis of COVID reinfection rates.

The study dealt only with those people who had not had any vaccinations and addressed the effectiveness of natural immunity from preventing infections and from the worst symptoms of the disease.

Prior infections in general didn’t prevent people from getting reinfected, but it does “protect you from getting a really bad disease and dying,” Fries said.

Long COVID

Even with the number of people contracting COVID declining, the overall population of people battling symptoms of long COVID, which can still include anything from loss of smell and taste to chronic fatigue, continues to increase.

“There’s a plethora of symptoms of long COVID,” Fries said. “We’ll have to figure out how to classify this and hopefully come up with better therapy. Right now, we can only symptomatically treat these patients.”

Dr. Sritha Rajupet, director of the Stony Brook Medicine Post-COVID Clinic, explained in an email that some patients who have lost their sense of smell or have a distorted sense of taste have tried a process called a stellate ganglion block “after several case reports and early research have shown that it could be helpful.”

In such a procedure, doctors inject a local anesthetic on either side of the voice box into the neck. Rajupet said that “additional research and clinical trials still have to be performed.”

Newborns and COVID

As for children infected with COVID soon after birth, doctors suggested that the impact has been manageable.

“The great majority of young children who contract COVID do quite well and recover fully,” Dr. Susan Walker, pediatrician with Stony Brook Children’s Services, explained in an email. “The impact on their development from having actually experienced COVID illness is minimal.”

Children hospitalized with more significant illness from COVID might experience temporary developmental regression which is common in children hospitalized for any reason. The developmental impact seems more tied to social isolation.

“Children born during the pandemic spent their first years of life rarely seeing adults or children other than those in their immediate family,” Walker said. “The result is that many of these kids became excessively stranger anxious and timid around others.”

The lost social opportunities, the pediatrician said, resulted in delays in the personal/social domain of development. She added, “The good news is that kids are resilient and, in time, with appropriate social stimulation, [these children] should be able to regroup and catch up developmentally.”

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Sean Clouston. Photo by Rachel Kidman

By Daniel Dunaief

The same wind that powers sailboats, makes kites dart through the air, and causes flags to flutter can make being outdoors in a group safer, particularly during the pandemic.

While public health officials have suggested that being outdoors with others amid the pandemic is safer than remaining inside, the strength of the wind can affect the level of protection provided by wide open spaces.

That’s the conclusion Sean Clouston, Associate Professor in the Program in Public Health and the Department of Family, Population and Preventive Medicine at the Renaissance School of Medicine at Stony Brook University, reached after studying public health data from 96,000 cases of COVID in Suffolk County from March 16, 2020 to December 31, 2020.

By combining public health data with the daily reports from the National Oceanic and Atmospheric Administration, Clouston found that days in which the temperature was between 60 and 84 degrees Fahrenheit and in which the wind was about 5 miles per hour or less had higher COVID-19 transmission than those days in which the wind speed was faster.

This kind of study, which was recently published in the journal BMC Infectious Disease, might affect the guidance policy makers provide to reduce the risk of COVID transmission during outdoor gatherings.

“If you’re imaging yourself as a policy maker and you want to contain COVID, what do you do?” Clouston asked rhetorically. Vaccines and masks are established tools. Ensuring airflow is higher might also be important, he suggested.

Indeed, amid the early days of the pandemic in 2020, public officials closed parks in Suffolk County for a while and eventually reopened them.

An alternative could be to provide access to parks where wind speed is also protective, or to reduce the use of parks where social distancing is difficult and where wind speed is lower.

At the same time, residents might want to protect themselves by putting out fans in their backyard or some other airflow devices to keep the flow of air moving during a social gathering, reducing the chance of transmitting the virus. People might want to avoid using tents that reduce the flow of air around them.

Additionally, people could eat out at restaurants where the airflow is stronger. 

Diners can search for places where the air “moves around, so the outdoor experience is as protective as possible,” Clouston said. He recognized that the data had some variability between when people who went outside might have contracted COVID. The air flow could increase and then decrease and the average length of time from exposure to symptoms and testing could differ between people.

“Any time we deal with humans, this is the problem,” Clouston said. Researchers can’t control for everything. Instead, they have to assume people make decisions in a consistent, but variable, way.

The larger data set, with close to 100,000 cases, enabled Clouston and his colleagues to average out the effects of the time when people reported their positive COVID tests.

For numerous cases, people had a good idea where and how they contracted COVID. Even when they were at outdoor events, such as a barbecue, some people had indoor parties where they ate together.

In addition, merely being outdoors didn’t reduce the risk if people were standing in the equivalent of stale air, where wind couldn’t reach them and help carry viral particles away from others who attended these events.

Being outside if the air isn’t moving is similar to being indoors in a space with a very large ceiling and a wide space between walls, he explained. It is safer than a small room, but it is not inherently safe on its own.

As for air circulation indoors, Clouston said people have suggested that moving air in buildings could reduce the spread of the virus.

Testing the effects of having HEPA filters or air filtration systems run continuously in hospitals  compared to areas that don’t have such units could reveal the benefit of having these air flow systems. Some studies have been done on this, although more work is ongoing, he said. 

Clouston suggested that other environmental conditions could also impact the transmissibility of the virus. The heat index, for example, might explain why wind speed might be important.

The heat index “might diminish the effect or make it stronger,” Clouston said. “It can push people indoors.”

Clouston worked on this study with Stony Brook colleagues in the Department of Family, Population and Preventive Medicine Assistant Professor Olga Morozova and Professor Jaymie Meliker. The team has worked with the Suffolk County Department of Health since 2020 on different aspects of COVID modeling.

Clouston was surprised that the research revealed a threshold model wind speed. He was also surprised to see that the speed was so low. “You only need a little airflow,” he explained.

The Stony Brook scientist looked at where the positive cases were located by zip code. The summer distribution and the spatial distribution was somewhat unclear, he said.

The spread of COVID was distributed by population size and density. Population size and density are likely more important than alterations in microclimate in the summer.

The analysis is important for places when and where outdoor exposures are most common, he explained.

“This may be true in the summer on Long Island or in the winter in southern states like Louisiana when outdoor activities are more comfortable,” he wrote in an email.

Clouston has several ongoing projects. He has papers discussing the role of social inequalities and COVID, a paper looking at clinical risk factors for COVID at Stony Brook Hospital, and one describing the initial wave of COVID in World Trade Center responders.

He would like to look at the effect of outdoor protests during 2020 on the spread of COVID, which would require data on attendance at those events and at the ones in New York City.

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Sean Clouston

By Daniel Dunaief

Every year, the country pauses on 9/11, remembering the victims of the terrorist attacks and reflecting on the safety and security of the country. At the same time, a Stony Brook University study continues not only to remember the first responders but also to understand the physical and mental consequences of the work police, firefighters and other first responders performed in the immediate aftermath of the attacks.

Benjamin Luft

Recently, Sean Clouston, an associate professor in the Department of Family, Population & Preventive Medicine at SBU Renaissance School of Medicine, and Ben Luft, the director of the SBU WTC Health and Wellness Program since 2003, published research in which they demonstrated a link between a protein commonly connected with Alzheimer’s disease to post-traumatic stress disorder, or PTSD, in first responders.

In a small preliminary study, the researchers found a difference in the level of the protein between first responders who are battling chronic PTSD and those who aren’t battling the condition. The Stony Brook scientists published their work in the journal Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring.

The researchers cautioned that the presence of the markers doesn’t necessarily indicate anything about present or future changes in cognitive function.“We don’t know the specificity of the markers,” Luft explained in an email.

Amyloid is generally considered the earliest marker of Alzheimer’s disease, which includes cognitive decline. Some people, however, have significant amounts of amyloid and don’t develop problems with their thinking. Neurodegenerative diseases without amyloid rarely have severe symptoms, which don’t appear to worsen with time.

“This paper doesn’t look at cognitive symptoms,” Clouston said. “We do have papers looking at cognitive impairment and other memory-based differences. It wasn’t a part of this paper.”

The newest research is part of an ongoing program in which the university follows 11,000 responders who came to the World Trade Center. The study for this paper involved a smaller subset of this population. This type of research can and does have application to other studies of people who have traumatic experiences, the scientists suggest.

Most traumatic experiences are unique to each person, as people who suffer physical and emotional trauma in combat often confront the aftereffects of head injuries. Among the first responder population who survived the attacks on 9/11, most of them “faired pretty well physically,” Clouston said. 

“We didn’t have a lot of head injuries. Understanding PTSD in this crowd is really useful for the literature as a whole because it allows us to focus on the long-term psychiatric fallout of an event without worrying about exposures that are different.”

The scientists had at least some idea of the timing and duration of exposures. This research suggests that it might be helpful to think about the kinds of problems that cognitive impairment can cause, which might involve managing other health-related problems.

Luft added that the population they are studying shows the benefit of immediate care. “One thing for sure is that the care of the first responders has to occur very quickly,” he said. “Now that we know the history, the greatest chance you have in mitigating the effect of this type of trauma is to deal with the problem from the get-go.” 

Sean Clouston with his daughter Quinn at Benner’s Farm in Setaukt. with his daughter Quinn. Photo by Rachel Kidman

First responders have benefited from psychotherapy as well as from various pharmacological treatments. Luft suggested that they might even benefit from having therapists available in the field, where they can receive near instantaneous psychological support.

In addition to the psychological trauma, first responders have had physical effects from their work in the aftermath of the attacks, such as respiratory and gastrointestinal problems, as well as autoimmunity issues.

People have these problems because “of the pro-inflammatory effect of PTSD itself,” said Luft. The researchers believe trauma can affect the immune system and the brain.

According to Clouston, the next step with this work is to replicate it with a larger scale. The experiment was “fairly expensive and untried in this population and novel in general, so we started small,” he explained in an email. The scientists would like to “get a larger range of responders and to examine issues surrounding symptomatology and other possible explanations.”

Clouston has been at Stony Brook for six years. Prior to his arrival on Long Island, he worked on a collaborative project that was shared between University College London and the University of Victoria. 

An expert in aging, he felt like his arrival came at just the right time for the WTC study, as many of the first responders were turning 50. After giving talks about the cognitive and physical effects of aging, he met Luft and the two decided to collaborate within six months of his arrival.

Clouston is focused on whether PTSD caused by the terrorist attacks themselves have caused early brain aging. A self-proclaimed genetics neophyte, he appreciates the opportunity to work with other researchers who have considerably more experience in searching for molecular signatures of trauma.

Clouston said his family has suffered through the trauma of cognitive decline during the aging process. His family’s struggles “definitely bring [the research] home,” reminding him of the “terror that many family members feel when they start noticing problems in their siblings, parents, spouses, etc.”

As for his work on the recent study, he said he is excited about the next steps. “Little is known about the subtypes of amyloid,” he suggested and there’s a “lot more to explore about the role [of this specific type] in the population. I do think it could be really informative about the types of symptoms.”

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