SUPPLEMENT Obstructive Sleep Apnea and World Trade Center Exposure Michelle S. Glaser, MPH, Neomi Shah, MD, Mayris P. Webber, DrPH, Rachel Zeig-Owens, MPH, Nadia Jaber, RPA-C, David W. Appel, MD, Charles B. Hall, PhD, Jessica Weakley, MPH, Hillel W. Cohen, DrPH, Lawrence Shulman, DO, Kerry Kelly, MD, and David Prezant, MD Objectives: To describe the proportion of at-risk World Trade Center (WTC)- exposed rescue/recovery workers with polysomnogram-confirmed obstruc- tive sleep apnea (OSA) and examine the relationship between WTC ex- posure, physician-diagnosed gastroesophageal reflux disease (GERD), and rhinosinusitis and OSA. Methods: A total of 636 male participants com- pleted polysomnography from September 24, 2010, to September 23, 2012. Obstructive sleep apnea was classified as mild, moderate, or severe. Associations were tested using nominal polytomous logistic regression. Results: Eighty-one percent of workers were diagnosed with OSA. Using logistic regression models, severe OSA was associated with WTC exposure on September 11, 2001 (odds ratio, 1.91; 95% confidence interval, 1.15 to 3.17), GERD (odds ratio, 2.75; 95% confidence interval, 1.33 to 5.70), and comorbid GERD/rhinosinusitis (odds ratio, 2.31; 95% confidence interval, 1.22 to 4.40). Conclusions: We found significant associations between se- vere OSA and WTC exposure, and with diseases prevalent in this population. Accordingly, we recommend clinical evaluation, including polysomnogra- phy, for patients with high WTC exposure, other OSA risk factors, and a physician diagnosis of GERD or comorbid GERD and rhinosinusitis. H undreds of studies have confirmed the relationship between work at the World Trade Center (WTC) disaster site and sub- sequent respiratory health issues. Lower respiratory conditions were quickly identified because of obvious symptoms of cough, short- ness of breath, and wheezing. Shortly thereafter, upper respiratory conditions, including gastroesophageal reflux disease (GERD) and rhinosinusitis, 1–3 became apparent and likewise were consistently reported across all WTC-exposed cohorts. 2,4–6 Over time, questions were raised whether other conditions, such as obstructive sleep apnea (OSA), were also associated with WTC exposure. Biologic plausibil- ity for a relationship between WTC exposure and OSA exists and is based on the known association between OSA and organic solvents, 7 which were found at the WTC site. 8 Alternatively, anecdotal observa- tions linking OSA to WTC exposure could be the result of cofactors with known high prevalence in this cohort, which include obesity, GERD, and rhinosinusitis. Our previous study of WTC-exposed Fire Department of the City of New York (FDNY) firefighters showed an association be- From the Department of Medicine (Ms Glaser, Dr Shah, Ms Zeig-Owens, Dr Appel, and Ms Weakley), Montefiore Medical Center, Bronx, NY; Bureau of Health Services (Ms Glaser, Ms Zeig-Owens, Ms Jaber, Ms Weakley, Dr Kelly, and Dr Prezant), Fire Department of the City of New York, Brook- lyn, NY; Department of Epidemiology and Population Health (Drs Webber, Hall, and Cohen), Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Department of Pulmonary Medicine (Drs Shah, Ap- pel, and Prezant), Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; and Pulmonary, Critical Care, and Sleep Medicine Department (Dr Shulman), ProHEALTH Care Associates, LLP, Lake Success, NY. The authors declare no conflicts of interest. This study (10-03-064E) was approved by the Institutional Review Board at Mon- tefiore Medical Center, Bronx, NY. Address correspondence to: Mayris P. Webber, DrPH, Bureau of Health Services, Fire Department of the City of New York, 9 Metrotech Center, Brooklyn, NY 11201 (webberm@fdny.nyc.gov). Copyright C  2014 by American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0000000000000283 tween symptoms of GERD and rhinosinusitis and high risk for OSA, as measured by the Berlin 9 sleep questionnaire, and found a dose–response relationship with WTC exposure (early high ex- posure vs later low exposure). 10 This study was symptom-based and therefore did not include diagnostic testing for OSA, GERD, or rhinosinusitis. 10 Confirmation of our findings in other WTC-exposed cohorts has been lacking, with most studies failing to find associ- ations between upper airway symptoms (GERD or rhinosinusitis) and OSA 11,12 or between OSA and WTC exposure (exposed vs unexposed). 11–13 Therefore, considerable uncertainty remains as to whether risk factors for OSA include WTC exposure or upper airway conditions. 14,15 Obstructive sleep apnea is a chronic disorder characterized by complete (apnea) or partial (hypopnea) obstructions of breath- ing during sleep. Obstructive sleep apnea is characterized by cycli- cal oxygen desaturation, sleep fragmentation, arousals from sleep, and increased sympathetic activity. Obstructive sleep apnea is an important disease to detect and treat as it is associated with de- pressed mood, irritability, cognitive dysfunction, 14 impaired glucose metabolism, 16 hypertension, 17,18 coronary heart disease, 19,20 cere- brovascular disease, 21,22 and an increased cancer mortality risk. 23 Known risk factors for OSA include male sex, increasing age, and a body mass index (BMI) of 30 kg/m 2 or more. 14,22,24 In non–WTC- exposed populations, it remains controversial whether OSA preva- lence is increased in patients with upper airway conditions. Some studies have shown GERD 25,26 and chronic rhinosinusitis (hereafter referred to as rhinosinusitis) 27,28 to be significantly associated with an increased prevalence of OSA, whereas others have not. 29,30 This study had two primary aims: (1) to determine the pro- portion of polysomnogram-confirmed diagnoses of OSA in FDNY- WTC-exposed first responders at increased risk for OSA; and (2) to examine the relationship between polysomnogram-diagnosed OSA, WTC exposure, and physician-diagnosed GERD or physician- diagnosed rhinosinusitis using FDNY medical records. METHODS The FDNY Bureau of Health Services performs periodic health evaluations on FDNY firefighters and emergency medical service personnel, every 12 to 18 months. These monitoring exam- inations include both physician examinations and, since 2001, self- administered physical and mental health questionnaires. This study (10-03-064E) was approved by the Institutional Review Board at Montefiore Medical Center (MMC), Bronx, New York. Oral consent was obtained from every participant. Participants The source population consisted of male FDNY firefighters and emergency medical service workers who first arrived at the WTC site within the first 2 weeks after September 11, 2001, and who completed polysomnography, at no cost to them, between September 24, 2010, and September 23, 2012. We obtained the final population in two ways. The first group of individuals (n = 1430), which we call the targeted outreach group, was recruited, by mail, to receive a polysomnogram, on the basis of having known OSA risk factors (eg, snoring, excessive daytime fatigue, and an elevated BMI between 30 and 40 kg/m 2 ). The second group was a convenience sample Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S30 JOEM  Volume 56, Number 10S, October 2014