Risk factors for post-9/11 chronic rhinosinusitis in Fire Department of the City of New York workers

The Impact of Ambient and Wildfire Air Pollution on Rhinosinusitis and Olfactory Dysfunction

PURPOSE OF REVIEW

With increasing industrialization, exposure to ambient and wildfire air pollution is projected to increase, necessitating further research to elucidate the complex relationship between exposure and sinonasal disease. This review aims to summarize the role of ambient and wildfire air pollution in chronic rhinosinusitis (CRS) and olfactory dysfunction and provide a perspective on gaps in the literature.

RECENT FINDINGS

Based on an emerging body of evidence, exposure to ambient air pollutants is correlated with the development of chronic rhinosinusitis in healthy individuals and increased symptom severity in CRS patients. Studies have also found a robust relationship between long-term exposure to ambient air pollutants and olfactory dysfunction. Ambient air pollution exposure is increasingly recognized to impact the development and sequelae of sinonasal pathophysiology. Given the rising number of wildfire events and worsening impacts of climate change, further study of the impact of wildfire-related air pollution is a crucial emerging field.

All-cause and cause-specific mortality in a cohort of WTC-exposed and non-WTC-exposed firefighters

OBJECTIVE

To compare mortality rates in World Trade Center (WTC)-exposed Fire Department of the City of New York (FDNY) firefighters with rates in similarly healthy, non-WTC-exposed/non-FDNY firefighters, and compare mortality in each firefighter cohort with the general population.

METHODS

10 786 male WTC-exposed FDNY firefighters and 8813 male non-WTC-exposed firefighters from other urban fire departments who were employed on 11 September 2001 were included in the analyses. Only WTC-exposed firefighters received health monitoring via the WTC Health Programme (WTCHP). Follow-up began 11 September 2001 and ended at the earlier of death date or 31 December 2016. Death data were obtained from the National Death Index and demographics from the fire departments. We estimated standardised mortality ratios (SMRs) in each firefighter cohort versus US males using demographic-specific US mortality rates. Poisson regression models estimated relative rates (RRs) of all-cause and cause-specific mortality in WTC-exposed versus non-WTC-exposed firefighters, controlling for age and race.

RESULTS

Between 11 September 2001 and 31 December 2016, there were 261 deaths among WTC-exposed firefighters and 605 among non-WTC-exposed. Both cohorts had reduced all-cause mortality compared with US males (SMR (95% CI)=0.30 (0.26 to 0.34) and 0.60 (0.55 to 0.65) in WTC-exposed and non-WTC-exposed, respectively). WTC-exposed firefighters also had lower rates of all-cause mortality (RR=0.54, 95% CI=0.49 to 0.59) and cancer-specific, cardiovascular-specific and respiratory disease-specific mortality compared with non-WTC-exposed firefighters.

CONCLUSION

Both firefighter cohorts had lower than expected all-cause mortality. Fifteen years post 11 September 2001, mortality was lower in WTC-exposed versus non-WTC-exposed firefighters. Lower mortality in the WTC-exposed suggests not just a healthy worker effect, but additional factors such as greater access to free health monitoring and treatment that they receive via the WTCHP.

World Trade Center Health Program best practices for diagnosing and treating chronic rhinosinusitis

The most frequent adverse physical health effect among World Trade Center Health Program (WTCHP) members is chronic rhinosinusitis (CRS), with some evidence supporting its association with the exposures to dust, gases, and toxicants. We selected the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICARS-RS-2021) as a comprehensive evidence-based guide on best practices for CRS diagnosis and treatment for the WTCHP.

Burn Pit Exposure Is Associated With Increased Sinonasal Disease

OBJECTIVE

The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease.

DESIGN

A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared.

RESULTS

One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively).

CONCLUSIONS

These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.

Air Pollution Exposure and the Development of Chronic Rhinosinusitis in the Active Duty Population

INTRODUCTION

It has been shown that combat environment exposure, including burn pits that produce particulate matter 2.5 (PM2.5), is associated with lower respiratory tract disease in the military population with increased hypothetical risk of upper respiratory disease, but no study has been done that examines the effects of non-combat environmental exposures on the development of chronic rhinosinusitis (CRS) in the active duty population. The primary goal of this study is to evaluate how air pollution exposure correlates to the development of CRS in active duty service members in the United States.

METHODS

The military electronic medical record was queried for active duty service members diagnosed with CRS by an otolaryngologist between January 2016 and January 2018, who have never deployed, stationed in the United States from 2015 to 2018 (n = 399). For each subject, the 1-year mean exposure of PM2.5, particulate matter 10 (PM10), nitrogen dioxide (NO2), and ozone was calculated. The control group was comprised of the same criteria except these patients were diagnosed with cerumen impaction and matched to the case group by age and gender (n = 399). Pollution exposure was calculated based on the Environmental Protection Agency's data tables for each subject. Values were calculated using chi-square test for categorical variables and the Mann-Whitney U-test for continuous variables.

RESULTS

Matched cases and controls (n = 399) with 33.1% male showed a statistically significant odds ratio (OR) of 5.99 (95% CI, 2.55-14.03) for exposure of every 5 µg/m3 of PM2.5 increase and the development of CRS when controlling for age, gender, and diagnosis year. When further adjusting for smoking status, the OR was still statistically significant at 3.15 (95% CI, 1.03-9.68). Particulate matter 10, ozone, and NO2 did not show any statistical significance. Odds ratios remained statistically significant when further adjusting for PM10 and ozone, but not NO2. Dose-dependent curves largely did not show a statistical significance; however, they did trend towards increased exposure of PM2.5 leading to an elevated OR.

CONCLUSION

This study showed that PM2.5 exposure is a major independent contributor to the development of CRS. Exposure to elevated levels produced statistically significant odds even among smokers and remained significant when controlling for other measured pollutants. There is still much to be understood about the genesis of CRS. From a pollution exposure perspective, a prospective cohort study would better elucidate the risk of the development of CRS among those exposed to other pollutants.

Hearing Loss Among World Trade Center Firefighters and Emergency Medical Service Workers

OBJECTIVE

To determine if World Trade Center (WTC) exposure is associated with hearing loss.

METHODS

Logistic regression to evaluate the immediate impact of WTC exposure and parametric survival analysis to assess longitudinal outcomes.

RESULTS

Those arriving on the morning of September 11, 2001 had elevated odds of low-frequency (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.04 to 1.47) and high-frequency (OR: 1.16; 95% CI: 1.02 to 1.31) hearing loss at their first post-September 11, 2001 examination. Longitudinally, participants arriving before September 13, 2001 and spending more than or equal to 6 months at the WTC-site had greater risk of hearing loss in the low frequencies (risk ratio [RR]: 1.31; 95% CI: 1.05 to 1.60) and high frequencies (RR: 1.37; 95% CI: 1.22 to 1.54). By 2016, 3194 (37%) had abnormal hearing sensitivity in either ear and 1751 (20%) in both ears.

CONCLUSIONS

More heavily WTC-exposed workers were at increased risk of hearing loss, and group differences persisted for at least 15 years. Those with abnormal hearing sensitivity may benefit from interventions such as hearing aids and other rehabilitation.

Systematic literature review of the epidemiology and clinical burden of chronic rhinosinusitis with nasal polyposis

OBJECTIVES

We conducted a systematic literature review (SLR) to determine the epidemiology and clinical burden of chronic rhinosinusitis with nasal polyps (CRSwNP) and to describe how the addition of biologics has affected outcomes for patients with CRSwNP.

METHODS

The SLR adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Embase, MEDLINE, and Evidence-Based Medicine Reviews databases were searched using OVID. Relevant studies published between 1 January 2008 and 8 February 2019, for epidemiology, and 1 January 2008 and 16 February 2019, for clinical burden, and relevant conference abstracts from 1 January 2017 to 7 March 2019, for epidemiology and 1 January 2017-16 February 2019 for clinical burden were included.

RESULTS

For the epidemiology and clinical burden SLR, 147 and 119 records, respectively, met the inclusion criteria. We found the prevalence of CRSwNP was 1-2.6% and was greater in men. Asthma, allergy, and allergic rhinitis were the most common comorbidities identified. Reported risk factors included asthma, gene polymorphisms, age, and eosinophilia. Studies indicated that dupilumab, mepolizumab, and omalizumab each improved different clinical outcomes. Non-biologics (drugs such as corticosteroids or antibiotics, surgery, or aspirin desensitization) improved clinical outcomes as well.

CONCLUSIONS

CRSwNP is fairly prevalent in the general population. Despite the significant efficacy of existing treatments, several unmet needs remain. The high burden of uncontrolled symptoms, frequent recurrence of nasal polyps after surgery, and long-term adverse effects of oral corticosteroids indicate that new therapies addressing these unmet needs should be developed. Although data on biologics from randomized controlled trials look promising, the efficacy of biologics in the real world has yet to be established. The SLR of the epidemiology and clinical burden of CRSwNP revealed key gaps in the literature. There was a paucity of prevalence data across many geographic areas, and no prevalence projections could be determined. Studies showed varying efficacy of non-biologics and no studies directly compared biologics for efficacy. Data regarding clinical efficacy of agents for eosinophilic CRSwNP or severe CRSwNP were lacking, and these patient populations would be served by more trials.

Adult chronic rhinosinusitis

Chronic rhinosinusitis (CRS) occurs in >10% of the adult population in Europe and the USA and can be differentiated into CRS without nasal polyps and CRS with nasal polyps (CRSwNP). Both phenotypes are characterized by a high disease burden and an overlapping spectrum of symptoms, with facial pain and loss of smell being the most differentiating. Great progress has been made in the understanding of CRS pathophysiology: from the epithelium and epithelial-mesenchymal transition to innate and adaptive immunity pathways and, finally, on the role of eosinophils and Staphylococcus aureus in the persistence of disease. Although clinical manifestations and diagnostic tools (including nasal endoscopy and imaging) have undergone major changes over the past few years, management (including pharmacotherapy, surgery and biologics) has experienced enormous progress based on the growing knowledge of key mediators in severe CRSwNP. The introduction of endotyping has led to a differentiation of 'tailored' surgical approaches, focusing on the mucosal concept in those with severe CRSwNP and on the identification of patients eligible for extended surgery and possibly biologics in the future.

Sex and Gender in Research on Healthcare Workers in Conflict Settings: A Scoping Review

The occupational health literature has established that sex and gender are associated with all dimensions of the workplace. Sex and/or gender (sex/gender) factors play an important role in shaping the experiences, exposures, and health outcomes of male and female healthcare providers working in war and conflict settings. This study aims to (1) assess how sex/gender is considered in the occupational health literature on healthcare workers in conflict settings, and (2) identify the gaps in incorporating sex/gender concepts in this literature. A scoping review was carried out and nine electronic databases were searched using a comprehensive search strategy. Two reviewers screened the titles/abstracts and full-texts of the studies using specific inclusion and exclusion criteria. Key information was extracted from the studies and four themes were identified. Of 7679 identified records, 47 were included for final review. The findings underlined the harsh working conditions of healthcare workers practicing in conflict zones and showed sex/gender similarities and differences in experiences, exposures and health outcomes. This review revealed a dearth of articles with adequate consideration of sex/gender in the study design. Sex/gender-sensitive research in occupational health is necessary to develop effective occupational health and safety policies to protect men and women healthcare workers in conflict settings.

Long-term Cardiovascular Disease Risk Among Firefighters After the World Trade Center Disaster

IMPORTANCE

Published studies examining the association between World Trade Center (WTC) exposure on and after September 11, 2001, and longer-term cardiovascular disease (CVD) outcomes have reported mixed findings.

OBJECTIVE

To assess whether WTC exposure was associated with elevated CVD risk in Fire Department of the City of New York (FDNY) firefighters.

DESIGN, SETTINGS, AND PARTICIPANTS

In this cohort study, the association between WTC exposure and the risk of CVD was assessed between September 11, 2001, and December 31, 2017, in FDNY male firefighters. Multivariable Cox regression analyses were used to estimate CVD risk in association with 2 measures of WTC exposure: arrival time to the WTC site and duration of work at the WTC site. Data analyses were conducted from May 1, 2018, to March 8, 2019.

MAIN OUTCOMES AND MEASURES

The primary CVD outcome included myocardial infarction, stroke, unstable angina, coronary artery surgery or angioplasty, or CVD death. The secondary outcome (all CVD) included all primary outcome events or any of the following: transient ischemic attack; stable angina, defined as either use of angina medication or cardiac catheterization without intervention; cardiomyopathy; and other CVD (aortic aneurysm, peripheral arterial vascular intervention, and carotid artery surgery).

RESULTS

There were 489 primary outcome events among 9796 male firefighters (mean [SD] age on September 11, 2001, was 40.3 [7.4] years and 7210 individuals [73.6%] were never smokers). Age-adjusted incident rates of CVD were higher for firefighters with greater WTC exposure. The multivariable adjusted hazard ratio (HR) for the primary CVD outcome was 1.44 (95% CI, 1.09-1.90) for the earliest arrival group compared with those who arrived later. Similarly, those who worked at the WTC site for 6 or more months vs those who worked less time at the site were more likely to have a CVD event (HR, 1.30; 95% CI, 1.05-1.60). Well-established CVD risk factors, including hypertension (HR, 1.41; 95% CI, 1.10-1.80), hypercholesterolemia (HR, 1.56; 95% CI, 1.28-1.91), diabetes (HR, 1.99; 95% CI, 1.33-2.98), and smoking (current: HR, 2.13; 95% CI, 1.68-2.70; former: HR, 1.55; 95% CI, 1.23-1.95), were significantly associated with CVD in the multivariable models. Analyses with the all-CVD outcome were similar.

CONCLUSIONS AND RELEVANCE

The findings of the study suggest a significant association between greater WTC exposure and long-term CVD risk. The findings appear to reinforce the importance of long-term monitoring of the health of survivors of disasters.