BACKGROUND: Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression are among the most common chronic health conditions linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We studied the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks, and assessed risk factors for having multiple co-morbid 9/11-related conditions.
METHODS: We studied 36,801 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 scale. Participants with asthma, GERD, and at least one mental health condition at follow-up were considered to have multi-system 9/11-related comorbidities. Poor HRQOL was defined as reporting limited usual daily activities for >14 days during the month preceding the survey. Multivariable logistic regression was used to examine factors associated with multi-system comorbidities.
RESULTS: Among participants without pre-existing asthma, 13.8% reported asthma with onset after 9/11. Of those with post-9/11-onset asthma at baseline, 70.7% had LRS or were taking asthma medications at follow up. Among those without pre-9/11 GERD, 19.7% reported being diagnosed with GERD after 9/11; 87.5% of participants with GERS at baseline remained symptomatic at follow-up. Prevalence of PTSD and depression at follow-up was 14.8% and 16.8%, respectively. Among participants without pre-9/11 asthma or GERD, 15.6% had more than one 9/11-related condition at follow-up. HRQOL declined as the number of comorbidities increased. Of the 733 participants with multi-system comorbidities, 59.1% reported poor HRQOL, compared to 5.2% of participants with no 9/11-related conditions. Accounting for sociodemographic factors, rescue-recovery work [adjusted odds ratio (AOR) 3.8, 95% confidence interval (CI) 3.2-4.7], 9/11 dust cloud exposure (AOR 2.0, CI 1.6-2.4), and witnessing horrific events on 9/11 (AOR 1.8, CI 1.4-2.3) were associated with multi-system comorbidities.
CONCLUSIONS: Chronic 9/11-related health conditions remain highly prevalent among survivors of the WTC attacks. Comorbidity among 9/11-related conditions, often accompanied by poor quality of life, is common, and associated with rescue/recovery work and other acute exposures. These findings highlight the importance of careful coordination of physical and mental health care for survivors of complex environmental disasters.