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. 2020 Dec 4;17(23):9056.
doi: 10.3390/ijerph17239056.

Factors Predicting Treatment of World Trade Center-Related Lung Injury: A Longitudinal Cohort Study

Barbara Putman  1   2 , Lies Lahousse  1 , David G Goldfarb  3   4 , Rachel Zeig-Owens  3   4   5 , Theresa Schwartz  3   4 , Ankura Singh  3   4 , Brandon Vaeth  3   4 , Charles B Hall  6 , Elizabeth A Lancet  7 , Mayris P Webber  3   5 , Hillel W Cohen  5 , David J Prezant  3   4   7 , Michael D Weiden  2   3
Affiliations

Factors Predicting Treatment of World Trade Center-Related Lung Injury: A Longitudinal Cohort Study

Barbara Putman et al. Int J Environ Res Public Health. .

Abstract

The factors that predict treatment of lung injury in occupational cohorts are poorly defined. We aimed to identify patient characteristics associated with initiation of treatment with inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) >2 years among World Trade Center (WTC)-exposed firefighters. The study population included 8530 WTC-exposed firefighters. Multivariable logistic regression assessed the association of patient characteristics with ICS/LABA treatment for >2 years over two-year intervals from 11 September 2001-10 September 2017. Cox proportional hazards models measured the association of high probability of ICS/LABA initiation with actual ICS/LABA initiation in subsequent intervals. Between 11 September 2001-1 July 2018, 1629/8530 (19.1%) firefighters initiated ICS/LABA treatment for >2 years. Forced Expiratory Volume in 1 s (FEV1), wheeze, and dyspnea were consistently and independently associated with ICS/LABA treatment. High-intensity WTC exposure was associated with ICS/LABA between 11 September 2001-10 September 2003. The 10th percentile of risk for ICS/LABA between 11 September 2005-10 Septmeber 2007 was associated with a 3.32-fold increased hazard of actual ICS/LABA initiation in the subsequent 4 years. In firefighters with WTC exposure, FEV1, wheeze, and dyspnea were independently associated with prolonged ICS/LABA treatment. A high risk for treatment was identifiable from routine monitoring exam results years before treatment initiation.

Keywords: epidemiological studies; inhalation therapy; lung injury; occupational exposure; pulmonary function tests.

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Conflict of interest statement

B.P., L.L., D.G.G., R.Z.-O., T.S., A.S., B.V., C.B.H., M.P.W., H.W.C., D.J.P. and M.D.W. received support from grants and/or contracts from the National Institute of Occupational Safety and Health.

Figures

Figure 1
Figure 1
Flowchart of the study population. The source population included 10168 World Trade Center (WTC)-exposed male firefighters who were actively employed by FDNY on 11 September 2001, consented to research, and had at least one routine medical monitoring exam between 11 September 2001 and 1 July 2018. After applying exclusion criteria for individuals missing a spirometry in the initiation interval or having inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) initiation before first monitoring date, the analytic population included 9247 firefighters. Excluding individuals who initiated ICS/LABA for ≤2 years, a study population of 8530 firefighters was established to perform the main analyses.
Figure 2
Figure 2
Distribution of individuals initiating ICS/LABA for more than 2 years (n = 1629) per time interval. The first interval, 11 September 2001–10 September 2003, with 292 individuals starting ICS/LABA treatment, had the highest number. In the other, full 2-year intervals the numbers of individuals initiating ranged from 139 to 239 per 2-year time interval. The last interval 11 September 2017–1 July 2018, which was not a full 2-year interval (striped filling pattern), contained 34 individuals with ICS/LABA initiation.
Figure 3
Figure 3
Forest plots showing variables associated with the initiation of inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) treatment > 2 years between 11 September 2001 and 10 September 2017 (n = 1629) versus not initiating ICS/LABA treatment (n = 6901), created from multivariable logistic regression models examining the associations between medical monitoring exam covariates and initiation of prolonged ICS/LABA treatment (odds ratios (diamonds) and 95% confidence intervals (bars)). The models were adjusted for age and retirement status. Respiratory symptoms, such as wheeze, dyspnea, provocability, and lower FEV1, consistently predicted the early onset of lung injury defined by ICS/LABA treatment. High-intensity Word Trade Center exposure, based on arrival time, was strongly associated with ICS/LABA initiation soon after exposure. ‡ missing first two intervals because provocability data was not collected; * WTC exposure based on arrival at the WTC site: Morning of 11 September 2001 vs. 13 September 2001 or later.
Figure 3
Figure 3
Forest plots showing variables associated with the initiation of inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) treatment > 2 years between 11 September 2001 and 10 September 2017 (n = 1629) versus not initiating ICS/LABA treatment (n = 6901), created from multivariable logistic regression models examining the associations between medical monitoring exam covariates and initiation of prolonged ICS/LABA treatment (odds ratios (diamonds) and 95% confidence intervals (bars)). The models were adjusted for age and retirement status. Respiratory symptoms, such as wheeze, dyspnea, provocability, and lower FEV1, consistently predicted the early onset of lung injury defined by ICS/LABA treatment. High-intensity Word Trade Center exposure, based on arrival time, was strongly associated with ICS/LABA initiation soon after exposure. ‡ missing first two intervals because provocability data was not collected; * WTC exposure based on arrival at the WTC site: Morning of 11 September 2001 vs. 13 September 2001 or later.
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