Correspondence
Cough and Bronchial Responsiveness in Firefighters at the World Trade Center Site
N Engl J Med 2003; 348:76-77January 2, 2003
- Article
To the Editor:
Prezant and colleagues (Sept. 12 issue)1 describe cough and bronchial responsiveness in firefighters at the World Trade Center. They attribute the observed sinusitis, bronchial hyperreactivity, and bronchial responsiveness to dust inhalation. Although the dust had settled after six days, the peak incidence of disability occurred in late October and early November. This points to an illness with two phases, with World Trade Center cough representing a late-phase reaction. If this is to be an adequate explanation, we must account for sinusitis, bronchial hyperreactivity, and bronchial responsiveness among healthy firefighters exposed to the dust from the collapsed buildings. Aspergillus is known to cause allergic bronchopulmonary aspergillosis and allergic sinusitis. A well-known risk factor is building demolition.2 The incubation period ranges between 36 hours and three months.3 The thickening of the bronchial walls seen by Prezant and colleagues on computed tomography (CT) is compatible with this diagnosis.4 The decrease in forced vital capacity (FVC) and forced expiratory volume in one second (FEV1), with the stable FEV1/FVC ratio and normal carbon monoxide diffusing capacity, is also consistent with a diagnosis of pulmonary aspergillosis.4 Findings on bronchoscopy, findings on examination of bronchoalveolar-lavage specimens, and specific IgE test results are not reported; these tests could have helped establish the diagnosis. Aspergillus-specific IgE should be sought in persons with World Trade Center cough, and polymerase-chain-reaction (PCR) analysis to detect aspergillus should be performed in available sputum or bronchoalveolar-lavage specimens.
4 ReferencesBernard L. Hanson, M.D.
Bernard Sztern, M.D.
Hôpitaux Iris Sud, 1190 Brussels, Belgium
bernard.hanson@swing. be 1
Prezant DJ ,Weiden M ,Banauch GI , et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med 2002;347:806-815
Full Text | Web of Science | Medline2
Cheng SM ,Streifel AJ . Infection control considerations during construction activities: land excavation and demolition. Am J Infect Control 2001;29:321-328
CrossRef | Web of Science | Medline3
Denning DW. Aspergillus species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 5th ed. Vol. 2. Philadelphia: Churchill Livingstone, 2000:2674-85.
4
Case Records of the Massachusetts General Hospital (Case 24-2001). N Engl J Med 2001;345:443-449
Full Text | Web of Science | Medline
To the Editor:
Prezant et al. and Scanlon, in his editorial,1 cite a report2 that suggests that occupational exposures during the World Trade Center collapse did not exceed established limits. According to the Occupational Safety and Health Administration,3,4 exposure to levels of asbestos at the World Trade Center commonly exceeded regulatory limits, thus contradicting the cited report.2 However, the Occupational Safety and Health Administration subsequently modified its methods for measurement of asbestos fibers. It therefore appears that for political convenience there has been a change in the regulatory requirements for measuring exposure and enforcing personal protection. Although, in such a disaster, this type of change can be understandable, it is never a factor in private industry.4 Many local New York City residents were probably exposed to similar concentrations of dust5 and do not constitute a healthy population of workers, but little attention was given to their well-being by regulators.
Health professionals need to eliminate any tendencies to acquiesce to political pressures. The firefighters, because of their profession, accepted the risks of exposure, whereas residents of the area of the World Trade Center did not. Issues relating to future effects on health in all the groups exposed need to be addressed. As correctly pointed out by Prezant and colleagues, there needs to be a change in the way regulators look at disasters. The scope of their attention should include all disasters, both public and private.
5 ReferencesJohn H. Lange
Envirosafe Training and Consultants, Pittsburgh, PA 15239
john.pam. lange@worldnet. att. net 1
Scanlon PD . World Trade Center cough -- a lingering legacy and a cautionary tale. N Engl J Med 2002;347:840-842
Full Text | Web of Science | Medline2
Occupational exposures to air contaminants at the World Trade Center disaster site -- New York, September-October 2001. MMWR Morb Mortal Wkly Rep 2002;51:453-456
Medline3
Update asbestos data: continue to reassure public of contamination fears. Washington, D.C.: Occupational Safety & Health Administration, September 2001. (Accessed November 26, 2002, at http://www.osha.gov.)
4
Lange JH . Has the indoor and built environment started changing modern health? Indoor Built Environ 2002;11:119-122
Web of Science5
Ilgren EB . Health risks from exposures to asbestos, metals, and various chemicals due to collapse of the World Trade Center: an environmental residential survey with a commentary related to ground zero workers. Indoor Built Environ 2001;10:361-383
Web of Science
Author/Editor Response
We agree with Drs. Hanson and Sztern that mold, including aspergillus, is a well-known contaminant in buildings and that aspergillosis (both allergic bronchopulmonary aspergillosis and allergic sinusitis) may result from the inhalation of dust released during building demolition.1 However, we are unaware of reports linking aspergillus inhalation to gastroesophageal reflux disorder, another important clinical finding in our cohort. The World Trade Center collapse was not a typical collapse or demolition. Towers 1 and 2 and Building 7 collapsed under intense thermal activity, and their weight resulted in the pulverization of nearly all nonsteel building materials. The intense heat and pulverization may have resulted in substantial decontamination of preexisting fungal materials.
The pulmonary-function abnormalities observed in the firefighters we examined may be consistent with allergic bronchopulmonary aspergillosis, but they are also consistent with inhalation exposure to inorganic particulate matter. Our findings indicate that the incidence of airway hyperreactivity and cough was greater in those present during the collapse than in those arriving during the first week after the collapse, suggesting that there was an immediate response to inorganic particulate matter.
It is true that the peak incidence of disability occurred in October and November 2001, but there are many plausible explanations other than the late-phase reaction suggested by Drs. Hanson and Sztern. For example, few firefighters were willing to report any medical symptoms during the first month after the collapse, a time when rescue efforts were of paramount importance. Although bronchial-wall thickening may be seen on high-resolution CT in persons with this diagnosis, the more typical finding of central-airway bronchiectasis2 has not been observed in any of the firefighters examined to date. The results of bronchoscopy, bronchoalveolar lavage, PCR analysis for aspergillus, and specific IgE testing were not obtained because they were beyond the scope of our investigation. The often-reported finding of peripheral eosinophilia3 was not identified in any of the persons with cough whom we describe, nor was it documented in any of the more than 10,000 New York City firefighters who underwent the New York City Fire Department's World Trade Center medical evaluation. However, we did find one New York City firefighter who presented with severe dyspnea, peripheral eosinophilia, hypoxia, and bilateral alveolitis, which resolved with systemic corticosteroid treatment. The serum and bronchoalveolar-lavage IgE levels were normal, and tests for serum aspergillus precipitins were negative.4
4 ReferencesDavid Prezant, M.D.
Michael Weiden, M.D.
Kerry J. Kelly, M.D.
New York City Fire Department Bureau of Health, Brooklyn, NY 11201
prezand@fdny.nyc. gov 1
Cheng SM ,Streifel AJ . Infection control considerations during construction activities: land excavation and demolition. Am J Infect Control 2001;29:321-328
CrossRef | Web of Science | Medline2
Neeld DA ,Goodman LR ,Gurney AW , et al. Computerized tomography in the evaluation of allergic bronchopulmonary aspergillosis. Am Rev Respir Dis 1990;142:1200-1205
Web of Science | Medline3
Denning DW. Aspergillus species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 5th ed. Vol. 2. Philadelphia: Churchill Livingstone, 2000:2674-85.
4
Rom WN ,Weiden M ,Garcia R , et al. Acute eosinophilic pneumonia in a New York City firefighter exposed to World Trade Center dust. Am J Respir Crit Care Med 2002;166:797-800
CrossRef | Web of Science | Medline
- Citing Articles (5)
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E. N. Schachter, E. Zuskin, J. Pucarin-Cvetkovic, A. Chiarelli, S. Goswami. (2011) Response to Oyster Mushroom (Pleurotus ostreatus) Extract by Sensitized and Nonsensitized Guinea Pig Trachea. Lung 189:4, 305-310
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Harvey I. Pass, Michele Carbone. (2009) Current Status of Screening for Malignant Pleural Mesothelioma. Seminars in Thoracic and Cardiovascular Surgery 21:2, 97-104
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Raphael Bueno. (2005) Multimodality Treatments in the Management of Malignant Pleural Mesothelioma: An Update. Hematology/Oncology Clinics of North America 19:6, 1089-1097
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J. H. Lange. (2003) Health Effects of Local Residents Near the World Trade Center: Have They Been Forgotten?. Journal of Occupational and Environmental Medicine 45:5, 465-466
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Barbara A. Goldrick. (2003) Allergic Aspergillosis. AJN, American Journal of Nursing 103:4, 89
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