Respiratory Health Among First Responders

This year marks the 19th Anniversary of the September 11th attacks of 2001. Immediate deaths involved those at the World Trade Center (WTC) in New York City (NYC), the Pentagon, and the passengers on board the four aircrafts, which included Shanksville, Pennsylvania, and Arlington County, Virginia. Of the 2,977 lives lost that day, 343 firefighters and 71 law enforcement officers perished. As the day approaches, we pause to remember the victims, the families, and survivors affected by this horrific event.

New York City Firefighters

Firefighters work at the site of the World Trade Center terrorist attack in New York City on September 11, 2001.
Photo: Mark Lennihan/Associated Press

With specific regard to the WTC and ground zero, the information provided by the NYC Commissioners office states that the rescue and recovery clean-up of the 1.8 million tons of wreckage took 9 months to complete. Firefighters, Emergency Medical Technician (EMT), law enforcement officers, and volunteers joined in the effort to recover and rebuild, putting their respiratory health at risk in the process.

Firefighters are regularly at an increased risk of developing respiratory conditions due to occupational exposures. In fact, researchers have found an increased prevalence of chronic obstructive pulmonary disease (COPD) among nonsmoking workers. According to the Centers for Disease Control and Prevention (CDC), nonsmokers account for an estimated 26 -53% of COPD cases attributed to occupational exposures. Inhalation of occupational elements can lead to short- and long-term effects on the respiratory system. During the “knockdown” phase, firefighters are actively fighting the fire. During the “overhaul” phase, firefighters have extinguished the fire, and embers and smoldering flames have subsided. Consequently,  both lead to exposure to toxins and respiratory irritants such as sulfur dioxide, aldehydes, and hydrogen chloride.

The World Trade Center Health Program was implemented to manage the ongoing health effects of the 9/11 attacks. As of December 2017, the program has reported asthma, COPD, various cancers, and gastroesophageal reflux disease (GERD) to be the most common conditions they treat. Air pollution experts suggest that along with pulverized building materials and electronic equipment, first responders were also inhaling things such as burning jet fuel, plastics, metal, and fiberglass. Under normal circumstances, firefighters are not exposed to this magnitude of inhaled pollutants.

The events of 9/11 highlight the essential need for firefighters to use self-contained breathing apparatus (SCBA). The use of an SCBA can prevent or slow the progression of developing respiratory conditions such as asthma and COPD, prevent inhalation of pulmonary irritants, and reduce the risk of smoke inhalation injuries. The significance of COPD among firefighters is like that of a problem in developing countries where household air pollution is a concern. According to the World Health Organization (WHO), 25% of deaths attributed to COPD involve low- and middle-income countries and are due to the exposure to household air pollution. Women who are exposed to high levels of indoor smoke and are twice as likely to develop COPD as compared to women that use cleaner fuels and technologies.

Lung disease among firefighters is studied routinely. Schermer TR, et al. set out to compare occupational exposures, use of respiratory protective devices, and their association with health-related quality of life among metropolitan firefighters. A cross-sectional cohort analysis of the South Australian metropolitan fire-fighter was performed. The questionnaire involved 570 participants and analyzed respiratory symptoms, medical conditions, occupational tasks and exposures, and the consistency of respiratory protection. Of the results reported, 91% of firefighters that participated reported relevant occupational exposures in the last year. Asthma accounted for 4% and COPD for 7% as a diagnosis based on criteria answered in the questionnaire. Firefighters with asthma reported they had been sick due to occupational exposures twice as often as those with COPD, emphysema, or chronic bronchitis.

Our medical textbooks teach us that asthma and COPD are two distinct disorders however there is increasing evidence that many patients may have features of both, now referred to as Asthma-COPD overlap (ACO).  Asthma is classified by having intermittent symptoms early on and has an effective response to inhaled medication therapy. COPD however is generally is associated with a late-onset, a patient typically has a slow progression of symptoms, poor response to inhaled therapy, and often associated with long-term smoking. COPD patients are prescribed long term oxygen therapy (LTOT) manage their symptoms whereas most asthma patients are not. Patients with ACO have a decline in the quality of life and higher mortality compared with patients who have either isolated-COPD or isolated asthma.

Firefighters at ground zero after the attacks at the World Trade Center

Firefighters at ground zero in New York City shortly after the attacks on the World Trade Center (WTC). September 11, 2001.

In a similar 2016 study by Aldrich TK et al., lung function trajectories in WTC firefighters over the course of 13 years were observed. Information was collected from 10,641 WTC-exposed NYC firefighters. Significant findings revealed that on average, firefighters lost 10% of their lung function after 9/11, and >10% developed new obstructive airway disease. The data also revealed that there was a little recovery in lung function over a span of the first 6 years. First responders, those arriving at ground zero the morning of 9/11 had a significant pulmonary function test (PFT) results, having an FEV1 < lower limit of normal as compared to those that arrived toward the end of the day. Of those studied, Aldrich et al. did separate the subjects into never smokers, current smokers, and previous smokers. Current smokers had existing lung function damage, but the significance of the findings is that 65% of the firefighters never smoked yet make up the 10% of those who have a new diagnosis of obstructive disease. Smoking cessation plays a significant role in any patient population however extremely imperative in the firefighter population. While the damage caused by the WTC exposure is immutable, focusing on improving PFT metrics can monitor the progression of the long-term respiratory conditions.

The National Institute for Occupational Safety and Health (NIOSH) is a federal agency and organization that conducts research and makes recommendations to prevent work-related injuries and illnesses. According to NIOSH, mortality from lung cancer, heart disease, and COPD are three diseases traditionally associated with firefighting. Based on previous research collected, current smokers may tend to overlook signs and symptoms of COPD which could lead to delay in care and treatment of lung damage. As with our current COVID-19 pandemic, great importance is placed on the use of personal protective equipment (PPE). NIOSH Respiratory Protection Week is September 8-11, 2020. Their focus for the last 101 years has been to compile resources and determine proper respiratory protection and maximize the availability of respiratory protection in addition to designing innovative respirators.  

The International Association of Fire Fighters (IAFF) is another key organization among firefighters. Information provided by the IAFF suggests that depending on when a diagnosis is made of COPD and how aggressively firefighters can change exposures and behaviors, further decline in lung function can be decreased with appropriate PPE. As mentioned before from what we know with the events of the 9/11 attacks, the use of SCBA equipment by firefighters can slow the progression of respiratory diseases by preventing inhalation of pulmonary irritants and reduce the risk of smoke inhalation injuries. Beyond that, specific attention to the consistent use of respiratory protection devices in employees who have underlying chronic respiratory conditions is equally important.

Among the common respiratory conditions firefighters face, cancer is among the highest diagnosed within the profession. In 2010, NIOSH published a study that included nearly 30,000 firefighters who were employed from 1950 – 2009. Findings suggested that compared to U.S. population rates, firefighters had a 9% increase in cancer diagnosis and a 14% increase in cancer-related deaths. This information is consistent with a cancer diagnosis that has been trended from the WTC Health Program. Each year more firefighters have lost their life due to various types of cancer, linked back to the exposure of the 9/11 attacks.

The dedication and bravery the multitude of first responders from 9/11 and all firefighters today exhibit should never be forgotten. Integrity, respect, and compassion are qualities these men and women display daily all while risking their lives and health. Let us pause to commemorate the lives of those we lost that day and join in the effort to bring safety awareness to this vulnerable population who is at increased risk of developing respiratory health issues and fatal conditions.