The upper respiratory pyramid: early factors and later treatment utilization in World Trade Center exposed firefighters

Twenty-Year Reflection on the Impact of World Trade Center Exposure on Pulmonary Outcomes in Fire Department of the City of New York (FDNY) Rescue and Recovery Workers

After the terrorist attacks on September 11, 2001 (9/11), many rescue/recovery workers developed respiratory symptoms and pulmonary diseases due to their extensive World Trade Center (WTC) dust cloud exposure. Nearly all Fire Department of the City of New York (FDNY) workers were present within 48 h of 9/11 and for the next several months. Since the FDNY had a well-established occupational health service for its firefighters and Emergency Medical Services workers prior to 9/11, the FDNY was able to immediately start a rigorous monitoring and treatment program for its WTC-exposed workers. As a result, respiratory symptoms and diseases were identified soon after 9/11. This focused review summarizes the WTC-related respiratory diseases that developed in the FDNY cohort after 9/11, including WTC cough syndrome, obstructive airways disease, accelerated lung function decline, airway hyperreactivity, sarcoidosis, and obstructive sleep apnea. Additionally, an extensive array of biomarkers has been identified as associated with WTC-related respiratory disease. Future research efforts will not only focus on further phenotyping/treating WTC-related respiratory disease but also on additional diseases associated with WTC exposure, especially those that take decades to develop, such as cardiovascular disease, cancer, and interstitial lung disease.

The Physical and Mental Health Challenges Experienced by 9/11 First Responders and Recovery Workers: A Review of the Literature

Introduction:

In the years following the September 11, 2001 terrorist attacks in New York (USA), otherwise known as 9/11, first responders and recovery workers began experiencing a range of physical and mental health challenges. Publications documenting these provide an important evidence-base identifying exposure-related health challenges associated with environmental exposures from the World Trade Center (WTC) site and describe the key lessons learned regarding both physical and mental health challenges (including symptoms and defined conditions) from the 9/11 disaster response.

Methods:

A systematic literature review was conducted using the MEDLINE, PubMed, CINAHL, and PsychInfo databases (September 11, 2001 to September 11, 2018) using relevant search terms, truncation symbols, and Boolean combination functions. Publications were limited to journal articles that documented the physical or mental health challenges of 9/11 on first responders or recovery workers.

Results:

A total of 156 publications were retrieved by the search strategy. The majority (55%) reported a quantitative methodology, while only seven percent reported the use of a qualitative research methodology. Firefighters were the group of responders most frequently reported in the literature (35%), while 37% of publications reported on research that included a mix of first responders and recovery workers. Physical health was the focus of the majority of publications (57%). Among the challenges, respiratory issues were the physical health condition most frequently reported in publications, while posttraumatic stress disorder (PTSD) was the most frequent mental health condition reported on. Publications were published in a broad range of multi-disciplinary journals (n = 75).

Discussion:

These findings will go some way to filling the current gap in the 9/11 evidence-base regarding the understanding of the long-term health challenges for first responders and recovery workers.

Acute effects of smoke exposure on airway and systemic inflammation in forest firefighters

Introduction

The aim of this study was to assess respiratory health and airway and systemic inflammation in professional forest firefighters post firefighting.

Methods

A total of 60 firefighters who participated in forest firefighting operations in Greece during 2008 were included in the study. A questionnaire consisting of symptoms and exposure, pulmonary function, atopy, bronchial hyperresponsiveness, and markers of inflammation in induced sputum, serum, and bronchoalveolar lavage (BAL) fluid was assessed.

Results

A measurable eosinophilic and neutrophilic inflammation was shown to be induced in the bronchial airways after acute exposure during forest firefighting. This was associated with increased respiratory symptoms from the upper and lower respiratory tract and pulmonary function impairment. Additionally, a measurable systemic inflammatory response was demonstrated. This study showed that acute exposure during forest firefighting significantly augments the intensity of airway and systemic inflammation in relation to the baseline inflammatory background due to chronic exposure.

Conclusion

The repeated acute exposures during firefighting augment the burden of chronic airway and systemic inflammation and may eventually lead to allergic sensitization of the airways and increased incidence of rhinitis and asthma after prolonged exposure.

Blood Eosinophils and World Trade Center Exposure Predict Surgery in Chronic Rhinosinusitis. A 13.5-Year Longitudinal Study

RATIONALE

The World Trade Center (WTC) collapse generated caustic airborne particulates that caused chronic rhinosinusitis in exposed Fire Department of New York firefighters. Surgery was performed when symptoms remained uncontrolled despite medical management.

OBJECTIVES

To identify predictors of surgical intervention for chronic rhinosinusitis in firefighters exposed to airborne irritants at the WTC collapse site.

METHODS

We assessed in 8,227 firefighters with WTC exposure between September 11, 2001 (9/11), and September 25, 2001, including WTC-site arrival time, months of rescue and recovery work, and eosinophil concentration measured between 9/11 and March 10, 2003. We assessed the association of serum cytokines and immunoglobulins with eosinophil concentration and surgery for rhinosinusitis in 112 surgical cases and 376 control subjects with serum available from the first 6 months after exposure to the WTC collapse site.

MEASUREMENTS AND MAIN RESULTS

Between 9/11 and March 10, 2015, the surgery rate was 0.47 cases per 100 person-years. In the first 18 months post-9/11, surgical patients had higher mean blood eosinophil levels than study cohort patients (219 ± 155 vs. 191 ± 134; P < 0.0001). Increased surgery risk was associated with increasing blood eosinophil counts (hazard ratio [HR], 1.12 per 100 cells/μl; 95% confidence interval [CI], 1.07-1.17; P < 0.001); arriving at the WTC site on 9/11 or September 12, 2001 (HR, 1.43; 95% CI, 1.04-1.99; P = 0.03); and working 6 months or longer at the WTC site (HR, 1.48; 95% CI, 1.14-1.93; P < 0.01). Median blood eosinophil levels for surgical patients were above levels for the cohort in all 18-month intervals March 11, 2000, through March 10, 2015, using 51,163 measurements representing 97,733 person-years of observation. Increasing age, increasing IL-17A, and low IgA in serum from 2001 to 2002 predicted blood eosinophil concentration in surgical patients but not in control subjects (R(2) = 0.26, P < 0.0001; vs. R(2) = 0.008, P = 0.56).

CONCLUSIONS

Increasing blood eosinophil concentration predicts surgical intervention for chronic rhinosinusitis, particularly in those with intense acute and prolonged exposure to airborne irritants. WTC-exposed Fire Department of New York firefighters who underwent irritant-associated sinus surgery are immunologically different from the cohort. Surgical patients have a higher blood eosinophil levels that is associated with mediators of mucosal immunity.

Biomarkers of patient intrinsic risk for upper and lower airway injury after exposure to the World Trade Center atrocity

BACKGROUND

High rates of upper and lower airways disease have occurred in Fire Department of the City of New York (FDNY) workers exposed to the World Trade Center (WTC) disaster site. Most experienced acute declines in pulmonary function, and some continued to experience decline over 14 years of follow-up. Similarly, some with rhinosinusitis had symptoms requiring sinus surgery.

AIM

To increase generalizability of biomarker investigation, we describe biomarkers of risk for upper and lower airway injury that do not require stored serum.

METHODS

We review WTC biomarker literature.

RESULTS

Cytokines expressed in stored serum from the first 6 months post-9/11 can identify individuals at higher risk for future abnormal pulmonary function.

CONCLUSION

This research will help identify individuals at high risk of lung and sinus disease that develop after these, or future, irritant exposures for intensive monitoring and treatment. It may also identify targets for effective therapeutic interventions. Am. J. Ind. Med. 59:788-794, 2016. © 2016 Wiley Periodicals, Inc.

FDNY and 9/11: Clinical services and health outcomes in World Trade Center-exposed firefighters and EMS workers from 2001 to 2016

BACKGROUND

After the World Trade Center (WTC) attacks on September 11, 2001, the Fire Department of the City of New York (FDNY) instituted a WTC medical monitoring and treatment program and established a data center to document health outcomes in the WTC-exposed workforce of ∼16,000 firefighters and EMS workers.

METHODS

FDNY schedules routine monitoring exams every 12-18 months and physical and mental health treatment appointments, as required.

RESULTS

FDNY research studies have consistently found that early arrival to work and/or prolonged work at the WTC-site increased the risks for adverse physical and mental health outcomes. To date, a substantial proportion has been diagnosed with obstructive airways disease, chronic rhinosinusitis, and gastroesophageal reflux disease; a quarter has two or more of these conditions.

CONCLUSIONS

While much has been learned, the entire spectrum and trajectory of WTC-related disorders and their mechanisms of onset and persistence remain to be fully described. Am. J. Ind. Med. 59:695-708, 2016. © 2016 Wiley Periodicals, Inc.

Biomarkers of World Trade Center Particulate Matter Exposure: Physiology of Distal Airway and Blood Biomarkers that Predict FEV₁ Decline

Biomarkers can be important predictors of disease severity and progression. The intense exposure to particulates and other toxins from the destruction of the World Trade Center (WTC) overwhelmed the lung's normal protective barriers. The Fire Department of New York (FDNY) cohort not only had baseline pre-exposure lung function measures but also had serum samples banked soon after their WTC exposure. This well-phenotyped group of highly exposed first responders is an ideal cohort for biomarker discovery and eventual validation. Disease progression was heterogeneous in this group in that some individuals subsequently developed abnormal lung function while others recovered. Airflow obstruction predominated in WTC-exposed patients who were symptomatic. Multiple independent disease pathways may cause this abnormal FEV1 after irritant exposure. WTC exposure activates one or more of these pathways causing abnormal FEV1 in an individual. Our hypothesis was that serum biomarkers expressed within 6 months after WTC exposure reflect active disease pathways and predict subsequent development or protection from abnormal FEV1 below the lower limit of normal known as WTC-Lung Injury (WTC-LI). We utilized a nested case-cohort control design of previously healthy never smokers who sought subspecialty pulmonary evaluation to explore predictive biomarkers of WTC-LI. We have identified biomarkers of inflammation, metabolic derangement, protease/antiprotease balance, and vascular injury expressed in serum within 6 months of WTC exposure that were predictive of their FEV1 up to 7 years after their WTC exposure. Predicting future risk of airway injury after particulate exposures can focus monitoring and early treatment on a subset of patients in greatest need of these services.