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Arthritis Rheumatol. 2019 Nov 24. doi: 10.1002/art.41175. [Epub ahead of print]

Systemic autoimmune disease among adults exposed to the September 11, 2001, terrorist attack.

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New York City Department of Health and Mental Hygiene, Bureau of Epidemiology Services, Long Island City, NY.
Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY.
Division of Rheumatology, Hospital for Special Surgery, and Weill Cornell Medical College, New York, NY.
New York City Department of Health and Mental Hygiene, World Trade Center Health Registry, Long Island City, NY.



Autoimmune disease is an emerging condition among persons exposed to the September 11, 2001, attack on the World Trade Center (WTC). Components of the dust cloud resulting from the collapse of the WTC have been associated with systemic autoimmune diseases (SAID), as has posttraumatic stress disorder (PTSD). We sought to determine whether dust exposure and PTSD were associated with an increased risk of SAID in a 9/11-exposed cohort.


Among 43,133 WTC Health Registry enrollees, 2,786 self-reported a post-9/11 SAID. We obtained consent to review medical records to validate SAID diagnoses for 1,041. SAIDs were confirmed by classification criteria, rheumatologist diagnosis, or having been prescribed SAID medication. Controls were enrollees who denied an autoimmune disease diagnosis (n=37,017). We used multivariable log-binomial regression to examine the association between multiple 9/11 exposures and risk of post-9/11 SAID, stratifying by responders and community members.


We identified 118 persons with SAID. Rheumatoid arthritis was most frequent (n=71), followed by Sjӧgren's syndrome (n=22), systemic lupus erythematosus (n=20), myositis (n=9), mixed connective tissue disease (n=7), and scleroderma (n=4). Among 9/11 responders, those with intense dust cloud exposure had almost twice the risk of SAID (adjusted risk ratio =1.86, 95% CI=1.02-3.40). Community members with PTSD had a nearly three-fold increased risk of SAID.


Intense dust cloud exposure among responders and PTSD among community members were associated with a statistically significant increased risk of new-onset SAID. Clinicians treating 9/11 survivors should be aware of the potential increased risk of SAID in this population.


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