Objective Airborne endotoxin exposure has adverse and protective health effects. Studies show men have augmented acute inflammatory responses to endotoxin. In this longitudinal cohort study we investigated the effect of long-term exposure to endotoxin in cotton dust on health, and determined whether these effects differ by gender.

Methods In the Shanghai Textile Worker Study, 447 cotton and 472 control silk textile workers were followed from 1981 to 2011 with repeated measures of occupational endotoxin exposure, spirometry and health questionnaires. Impaired lung function was defined as a decline in forced expiratory volume in one second to less than the 5th centile of population predicted. Death was ascertained by death registries. We used Cox proportional hazards models to assess the effect of endotoxin exposure on the time to development of impaired lung function and death.

Results 128 deaths and 164 diagnoses of impaired lung function were ascertained between 1981 and 2011. HRs for the composite end point of impaired lung function or death was 1.47 (95% CI 1.09 to 1.97) for cotton vs silk workers and 1.04 (95% CI 1.01 to 1.07) per 10 000 endotoxin units (EU)/m³-years increase in exposure. HRs for all-cause mortality was 1.36 (95% CI 0.93 to 1.99) for cotton vs silk workers and 1.04 (95% CI 0.99 to 1.08) per 10 000 EU/m³-years. The risk associated with occupational endotoxin exposure was elevated only in men.

Conclusions Occupational endotoxin exposure is associated with an increase in the risk of impaired lung function and all-cause mortality in men.