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Title: Implementing the Personal Exposure Reporter (PER) System for Florida Fire Fighters: The Sylvester Firefighter Cancer Initiative


Authors: Barbara Millet, Alberto J. Caban-Martinez, Clay Ewing, Neal Niemczyk, Natasha Schaefer Solle,

and Erin N. Kobetz


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objective: Describe the design and implementation of a personal exposure record system for firefighters.




Background: Firefighters regularly are put into situations during work activities that place them at a greater risk for injury and illness than the general population.  Collecting objective information from emergency and fire incident response in the fire service is critical for monitoring carcinogenic exposure and identifying at risk personnel.  In the present study, we describe the development and implementation of the Personal Exposure Reporter (PER) system for firefighters. Methods: A user-centered design framework was leveraged to design and develop an exposure reporting system tailored to firefighters.  Based on firefighter focus groups, interviews, card sorts, and usability testing, six reporting domains were created: incident type, individual physical exposures, rehabilitation procedures, handling of safety gear, decontamination practices, and self-reported health symptoms. Results: An encrypted, university-based, HIPAA complaint web application was built allowing firefighters to keep a digital record of their individual on-the-job exposures.  The PER architecture uses a responsive design so that it can be accessed via mobile devices and desktop browsers. Conclusions:  The PER system provides firefighters with a lifelong, personal record of occupational exposures and supports occupational health and safety researchers with data to study firefighters’ exposure and health-related conditions.  The system offers an easy to use, non-punitive, readily accessible reporting mechanism designed to encourage voluntary reporting of occupational hazards exposure by Florida firefighters.

Title:  Understanding Cancer Risk among Florida Firefighters Using an Integrated Data-Driven Approach


Authors: Julia Seay, Alberto Caban-Martinez, Natasha Schaefer Solle, Feng Miao, Xing Wei, Tulay Koru-Sengul, and Hemant Ishwaran


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objective: Identify correlates of cancer among Florida firefighters.




Background: Firefighters are at increased risk of developing and dying from several types of cancer, including but not limited to lung, prostate, and colorectal cancers. However, there is a paucity of research and data sources unique to examining cancer risk factors for workers employed in the fire service. The few epidemiologic studies that have examined such factors among firefighters have found both general and work-related (e.g. occupational chemical exposures) risk factors may contribute to the development of cancer. These studies have been mostly retrospective and based on self-report claims data, and lack the methodological rigor to extensively explore potential links between such risk factors and cancer among firefighters. Methods: In 2015, the state of Florida funded the Firefighter Cancer Initiative (FCI), a large research program led and coordinated by multidisciplinary investigators at the University of Miami. The FCI includes several research studies collecting prospective data regarding cancer risk factors among both active and retired firefighters across the state of Florida. Importantly, there is substantial overlap in study participants between several of these studies (i.e. many firefighters participated in more than one of these studies).  However, there is a major scientific gap in that there is no infrastructure within FCI to regularly and systematically integrate data between each of these research studies. Results: The primary research goal of this hypotheses-generating pilot project is to merge and analyze current data streams between the aforementioned FCI projects.  Using machine learning methodology, we will examine various potential cancer risk factors, including sociodemographic, behavioral, occupational, and exposure variables, and their associations with cancer within our integrated FCI dataset. Conclusion: Preliminary results of this data analysis will be presented at the FCI Symposium.



Title:  Real-time exposure monitoring of Polyaromatic Hydrocarbons using Solid-State Sensor System in Florida Firefighter


Authors: Chitvan Killawala, Jeramy Baum, Umer Bakali, Katerina Santiago, Emre Dikici, Natasha Schaefer Solle, Kevin Moore, Erin Kobetz, Alberto Caban-Martinez, Sapna Deo, Sylvia Daunert


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: Assess the real time exposure of various polyaromatic hydrocarbon (PAH) to firefighters during fire. Demonstrate the detection of PAHs using solid state sensor array in real time and in vicinity of active fire. Design a graphene based nanosensor to be able to detect selectively detect various PAHs.




Background: Studies on firefighters indicate high rates of exposure to toxic compounds including polyaromatic hydrocarbons (PAHs), known for their carcinogenicity. No readily available methods exist for determining the presence of these high-risk compounds in the field in real-time. Given high incidence of cancer in firefighters, it is necessary to detect PAHs in real-time to reduce the risk of exposure. We designed and deployed a portable detection system using solid-state sensors in controlled fire situations to evaluate their effectiveness in detecting PAHs. In addition, we have designed a nanosensor capable of outperforming current sensors in stability and selectivity. Methods: Sensor arrays were deployed at controlled burns. These burns employ well-documented fuel sources, allowing for reproducible output of volatilized compounds of risk during the burn. Sensor arrays were designed to allow for multiple sensors specific to different target compounds to operate in parallel. Fabrication of proposed nanosensors will be performed in a Class 1000 Cleanroom. Results: Sensor array responses measured at varying locations in the hot zone and warm zone of the controlled burn displayed significant differences in sensor activity consistent with expected PAH intensity in the area. Sensor responses to minor exposure events deviated from baseline compound response by at least 26%, 49%, and 63% and the largest exposures deviated by 48%, 76%, and 74% for Sensors 1, 2, and 3, respectively. Exposure events resulted in an average deviation of 31%, 55%, and 67% from the baseline. Results from fabrication will be detailed in the poster. Conclusions: The demonstration of sensor activity validates sensor arrays as a viable proof-of-concept for further development of deployable real-time PAH detectors as an active safety monitor in active fire situations. A fully-realized PAH detection system will help inform policy and regulations to advance firefighter safety in the field.



Title:  Evaluation of Carcinogenic Compound Exposure in South Florida Firefighters using Silicone-Based Passive Samplers in Controlled Burns


Authors: Umer Bakali, Jeramy Baum, Chitvan Killawala, Katerina Santiago, Emre Dikici, Natasha Schaefer Solle, Alberto Caban-Martinez, Erin Kobetz, Sapna Deo, Leonida Bachas, Sylvia Daunert\


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: Describe the utility of silicone-based passive samplers in monitoring firefighter exposure to toxic compounds.




Background: Firefighters are recognized by the National Institute for Occupational Safety and Health (NIOSH) to sustain significant occupational exposure to a variety of toxic and/or carcinogenic volatile and semi-volatile organic compounds. Polycyclic aromatic hydrocarbons (PAHs) are carcinogenic compounds that are generated during incomplete combustion and comprise a significant portion of the total exposure of active-duty firefighters. In order to evaluate the type, intensity, and source of PAH contamination among firefighter cohorts throughout South Florida, specially-prepared silicone wristbands were distributed for firefighters to wear at controlled burns used to simulate active fire situations. Methods: Silicone-based wristbands were repeatedly solvent-cleaned to remove impurities and improve their adsorptivity for volatile compounds; subsequently, they were dried overnight in a vacuum oven to remove solvent. Wristbands were distributed to firefighters to wear underneath their turnout gear immediately prior to a controlled burn. Following exposure, wristbands underwent solvent extraction. The extract was concentrated via evaporation under nitrogen and analyzed using GC-MS. Results: Firefighters wearing wristbands at the controlled burn were present in the area for approximately six hours. GC-MS reporting on the average concentrations of 15 select PAHs present in wristband extracts returned time-weighted average (TWA) exposures of between 3 to 22 mg/m3. By comparison, OSHA guidelines for eight-hour TWA exposures to PAHs is 3.5 mg/m3, indicating that firefighters sustain exposure up to seven times the recommended limit during an active fire situation, depending on the PAH in question. Conclusions: Results from repeated testing with wristbands are concordant with above-average exposure to various PAHs. Wristbands present a simple, inexpensive, and versatile means of documenting carcinogenic exposure in firefighters and other occupationally-exposed demographics. Further analyses of compounds will allow for logging personal profiles of PAH exposure for individuals to help mitigate future exposure.



Title:  Monitoring Firefighters for Longitudinal Occupational Exposures Using Epigenetic Markers


Authors: Alesia Jung, Jose Rueben Bautista, Jin Zhou, Timothy Jenkins, John Gulotta, Darin Wallentine, Stephanie Griffin, Devi Dearmon-Moore, Sally Littau, Jeffery Bugess


Submitting Author Affiliation: University of Arizona, Tucson, AZ, USA


Learning Objectives: Discuss why differential microRNA expression may be an important biomarker linking occupational exposures and future disease risk among firefighters. Describe the importance of expanding biological sample collection in the fire service to develop our knowledge of cancer incidence among firefighters.




Background: Firefighters have diverse exposures during fires, but we lack adequate biomarkers to assess future disease risk associated with these exposures.  MicroRNA (miRNA) expression in blood is associated with disease outcomes, most notably cancer.  We evaluated associations between surrogate fireground exposure measures and differential miRNA expression among firefighters, a group at increased cancer risk, over a two-year period. Methods: Surveys and blood samples were collected at baseline and follow-up from Tucson Fire Department new recruits.  We evaluated associations between length of follow-up and fireground exposures (total fire hours and total number of fires) with 9 a priori markers and a miRNA expression panel of 800 markers, using adjusted mixed effects models. Results: On average, the 52 male firefighters were 28.2 years old (standard deviation (SD)= 6), had a BMI of 26.4 kg/m^2 (SD=3.7) and were non-Hispanic white (>90%). Over 26.5 months (SD=4.3), they averaged 27.0 fire hours (SD=8.6) over 49.2 fire runs (SD=15.0).  In fully adjusted models (length of follow-up, fireground exposure, demographics, batch effects, Bonferroni correction, and time since most recent fire at follow-up), length of follow-up adjusted for fire hours was associated with 5 a priori miRNAs and 35 miRNA expression panel miRNAs.  Length of follow-up adjusted for number of fires was associated with 4 a priori miRNAs and 27 miRNA expression panel miRNAs.  The majority of these significant miRNAs were associated with increased cancer risk.  However, fire hours and number of fires were not associated with differential miRNA expression in the fully adjusted models. Conclusions: Results suggest that the evaluation of miRNAs can provide a measure of future disease risk following exposures in firefighters.  We need to clarify how factors such as job task, fire type, and protective occupational behaviors may influence the effect of surrogate fireground exposure measures on miRNA expression.



Title:  Post-Fire Turnout Gear Removal Practices Vary Among Florida Fire Departments


Authors: Andrew Faus, Raymond Balise, Paola Louzado-Feliciano, Kevin Griffin, Katerina Santiago, Natasha Schaefer Solle, David Lee, Erin Kobetz, Alberto Caban-Martinez


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: Compare the post-fire gear removal practices of firefighters in smaller departments (those with fewer firefighters per health and safety officer) to those of firefighters in larger departments (those with more firefighters per HSO). Formulate a hypothesis as to why these differences in gear removal practices exist between departments. Name the risks associated with improper gear removal practices (e.g. increased risk of cancer).




Background: Firefighters are at an increased risk of being diagnosed with cancer due to their exposure to different carcinogens such as polycyclic aromatic hydrocarbons (PAHs). A risk that can be reduced by removing and cleaning gear as soon as possible after overhaul is completed. Previous scientific investigations have not studied the length of time gear is kept on after a fire. We examine the association between firefighters per health and safety officer (HSO) and time to post-fire turnout gear item removal. Methods: Using a cross-sectional study design, an anonymous survey was administered to Florida firefighters at the 2018 Florida Fire Chiefs™ Safety and Health Conference. Time to gear removal after a fire was categorized and percentages of firefighters removing each piece of gear (e.g. hood, pants, etc.) in each time interval were reported. A contingency table analysis, using Fisher™s exact tests, examined the association between the number of firefighters per HSO and gear removal time. Results: Among the 138 respondents, representing 63 Florida fire departments, time to gear removal after overhaul varied. Gear items such as hoods were removed within 30 minutes (90.51%) whereas other items such as pants were left on for more than 30 minutes (40%). After adjusting for multiple comparisons, trends were seen as a function of the number of firefighters per HSO. Larger fire departments (i.e. more firefighters per safety officer) were more likely to remove certain gear items immediately when compared to smaller fire departments. A statistically significant difference between small and large fire departments was found in the time to remove jackets after a fire (67% of firefighters in larger departments removed their jacket immediately compared to 44% in smaller departments, p = 0.0165). Conclusions: Fire department workforce size is associated with time to remove gear items once overhaul is completed.

Title:  A State-level Gross Decontamination Bucket Intervention for Florida Firefighters: Reducing the Risk for Carcinogenic Exposures


Authors: Cynthia Beaver, Alberto Caban-Martinez, Natasha Schaefer Solle, Katerina Santiago, David Lee, Tulay Koru-Sengul, Jessica Diaz, Julius Halas, Erin Kobetz


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: Identify the benefits of decontamination bucket use among fire departments to reduce carcinogen exposure. Discuss strategies to maintain and increase the adoption and use of decontamination buckets in fire departments of various sizes in order to potentially reduce cancer risk among firefighters. 




Background: Firefighter field studies have documented that the use of dish soap, water, and scrubbing immediately after fire incident response is able to reduce carcinogen (i.e., polycyclic aromatic hydrocarbons [PAHs]) from bunker gear by 85%. In 2018, the Sylvester Firefighter Cancer Initiative in collaboration with the State Fire Marshall office distributed a total of 4,550 decontamination buckets to all fire trucks/engines in the State of Florida. In the present study we 1) describe the design, implementation and use of a gross decontamination bucket intervention among Florida fire services; and 2) estimate predictors of decontamination bucket use among participating fire services. Methods: We combined two data sources including the Florida fire department decontamination bucket distribution list containing fire department characteristics with survey data on decontamination bucket use collected from attendees of the 2018 Florida Fire Chiefs Health and Safety conference. Results: Sixty-two Florida fire departments represented by 138 Florida firefighter department leaders completed the decontamination bucket survey of which 83.3% reported receiving a decontamination bucket, 8.0% did not, and 8.7% were not sure if they received a bucket. Among fire departments who received a bucket, 86.3% reported using the bucket always to sometimes post fire incident response and 76.6% found the bucket useful. Over 83% of fire departments who received a bucket requested additional buckets. Firefighter department leaders reported using the bucket at least 1-5 times since receiving the bucket (88.2%) and had seen other firefighters use the bucket (61.9%). The top three most frequently recalled bucket items included: Scrub brushes (82.0%) detergents (81.2%), and hoses (81.2%). Medium-sized fire departments (101-500 Firefighters) were significantly more likely to report receiving a bucket compared to larger fire departments (odds ratio=7.86; 95%CI [1.32-46.74]). Conclusion: Decontamination buckets packed with items that reduce carcinogens from turnout gear are well accepted by fire departments.



Title:  Best practices for reducing firefighter exposure to contaminants in Quebec (Canada)


Authors: Josianne Roy, and Arnaud Courti


Submitting Author Affiliation: Campus Notre-Dame-de-Foy, Quebec, Canada


Learning Objectives: Describe best practices of Quebec firefighters aimed at reducing exposure to contaminants and improving overall health.




Background: During their daily firefighting activities, firefighters are exposed to many contaminants such as soot, polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs) and particulates. According to several epidemiological studies, frequent exposure to these hazardous substances are associated with elevated risks of cancer, various health problems and higher mortality risks for firefighters than in the general population. In response to this issue, firefighters began to review their practices to reduce their exposure to contaminants. In Québec (Canada), for the last few years we’ve been witnessing much more awareness and a major positive change in health and prevention culture. Taking into account the reality of fire departments and the resources available, firefighters in Québec have improved their practices based on various models found around the world and recent scientific studies. This qualitative study shows these new measures put in place by Québec firefighters to reduce direct and cross contamination during a fire. Methods: Data were collected through observations and personal interviews. A questionnaire was also administrated to health and safety officers. Descriptive and qualitative data analysis was performed. Results: The results of this analysis show that these new measures include education, training, personal protection (respiratory and skin), hygiene, decontamination on scene, revised doffing, cleaning procedures of PPE, transport of contaminated equipment, ventilation and revised operational guidelines. Individual or collective actions are presented for both large fire departments and those of small municipalities. Conclusion: Strategies and practices differ greatly from one city to another and there has been rapid change in recent years. Several fire departments are waiting for new studies to adapt certain practices because they imply higher costs and more complex operational procedures.



Title:  Evaluation of firefighter breastmilk toxicity and flame retardant contaminants


Authors: Shawn Beitel, Leanne Flahr, Christiane Hoppe-Jones, Fernanda Garavito, Sally Littau, Sara Jahnke, Jeffery Burgess, and Shane Snyder


Submitting Author Affiliation: University of Arizona, Tucson, AZ, USA


Learning Objectives: Assess the aryl hydrocarbon receptor mediated response in breastmilk of female firefighters before and after responding to structural fires




Background: Lactating firefighters are exposed to a variety of chemicals at a fire scene which could impact their breast feeding children. One class of chemicals of concern include flame retardants such as polybrominated diphenyl ethers (PBDEs), which are found in many household items, along with other dioxin-like compounds present during fire suppression. It is known that environmental exposures can result in chemicals being deposited into breastmilk as a form of excretion from the body. Unfortunately, there is little known about the safety of breastmilk after fire-ground and emergency response exposures, resulting in concern from mothers making decisions about breastfeeding and/or the use of breastmilk produced after responding to a fire. Therefore, our aim is to investigate the concentration of PBDEs along with the mixture of dioxin-like compounds by assessing the aryl hydrocarbon receptor (AhR) mediated response in breastmilk before and after responding to structural fires. Methods: Breastmilk samples were collected from female firefighters before and at several time points after responding to structural fires. Extraction of milk samples was conducted in order to quantify the concentration of 12 PBDEs by gas chromatography tandem mass spectroscopy, and to assess the AhR mediated response using the DR CALUX in vitro bioassay. Results: A detectable AhR mediated response was quantified with the DR CALUX bioassay in extracts of breastmilk samples collected before and after structural fires. There was an increase in the bioassay response observed in post-fire breastmilk samples compared to pre-fire. Though ongoing analysis of more individuals is needed, these preliminary results suggest that this bioassay is able to assess the mixture of dioxin-like compounds present in the breastmilk. Conclusion: More data should give insight into the time needed after responding to a fire for levels of these compounds and their toxicity to return to pre-fire levels.



Title:  Identification of compounds in the urine of firefighters that contribute to an in vitro PAH CALUX response


Authors: Shawn Beitel, Christiane Hoppe-Jones, Leanne Flahr, Fernanda Garavito, Sally Littau, Jeffery Burgess, and Shane Snyder


Submitting Author Affiliation: University of Arizona, Tucson, AZ, USA


Learning Objectives: Identify compounds in the urine of firefighters that are responsible for aryl hydrocarbon receptor activation



Background: Firefighters are exposed to a variety of contaminants from combustion at a fire scene. With a greater cancer incidence observed in firefighters compared to the general population, research is underway to characterize the toxicity of individual chemicals and complex mixtures to which firefighters are exposed using in vitro biomarkers of effect. One particular in vitro bioassay measures aryl hydrocarbon receptor (AhR) activation, which is a mechanism by which polycylic aromatic hydrocarbon (PAH) and other PAH-like compounds (such as dioxins, and furans) express toxicity. Our research group identified that extracts of urine from firefighters collected post-fire had greater AhR bioactivity than extracts of urine pre-fire. However, it is uncertain which compounds in the urine of firefighters post-fire are responsible for the increase in bioassay response. Therefore, our aim is to identify compounds in the urine of firefighters that are responsible for AhR activation. Methods: Urine samples obtained from training fires were extracted and analyzed with the in vitro bioassay and Gas Chromatography Quadrupole Time-of-Flight (GC-QTOF) to obtain the overall bioassay response and chemical profile of the mixture. An effect-directed-analysis approach using fractionation, bioassay testing and chemical analytical testing is being used to narrow down and identify the number of toxicants potentially responsible for the bioassay response. Results: Initial fractionation and analysis of the urine extracts using the in vitro bioassay identified three primary fractions of interest. With data analysis of the non-targeted chemical analysis underway, based on the fractionation pattern, it is hypothesized that some of the compounds responsible for the bioactivity might be more polar than the PAH-like compounds currently used to assess exposure. Conclusion: Additional analyses may identify new biomarkers of exposure that better correlate to the bioactivity observed.




Title:  Preparing New Jersey to participate in the National Firefighter Registry: compiling a directory of New Jersey volunteer fire departments and conducting interviews with department leadership


Authors: Taylor Black, Azanna Clemmings, Kathleen G. Black, Michael B. Steinberg, Judith M. Graber


Submitting Author Affiliation: Rutgers, The State University of New Jersey, New Jersey, USA


Learning Objectives: Discuss the challenges associated with creating a voluntary National Firefighter Registry and strategies stakeholders can use to engage fire departments. 



Background: In 2018, federal legislation [H.R. 931] directed the Centers for Disease Control and Prevention to develop and maintain a national, voluntary registry of all US firefighters to track their cancer incidence. A major challenge will be obtaining electronic data that can be linked with population-based cancer and vital status registries. To prepare New Jersey (NJ) to participate in the registry, we are investigating existing data from NJ volunteer fire departments (FD). The first step is compiling and validating a comprehensive directory of all NJ volunteer FDs. Methods: The directory is being created using data from the NJ Department of Community Affairs and the Fire-Community Assessment Response Evaluation System (FireCARES) (planned through a data use agreement). To assess accuracy, the data (e.g., roster numbers, contact information) will be verified by contacting up to 10% of departments. Using the directory as a sampling frame, we will select FDs for semi-structured interviews regarding FD characteristics, event response patterns, attitudes toward the registry, record-keeping practices, and the acceptability of confidential data sharing. Summary reports describing response themes and overall findings will be shared with government and community stakeholders. Results: Directory development is ongoing; a preliminary analysis identified 413 volunteer FDs in 12 counties (NJ has 21 counties), 86% of which have multiple forms of contact information available. Most FDs have fewer than 50 volunteer firefighters (mean 42.4, standard deviation (SD) 28.1) and few female firefighters (mean 2.05, SD 2.37). However, 7% of FDs were listed under multiple municipalities; duplications will be resolved during data validation. Conclusions: This project will contribute to the knowledge base of how volunteer FDs function and maintain records (e.g., recruitment, training, physical exams). This information will help inform development of the National Firefighter Registry which depends, in part, on its ability to engage volunteer FDs.




Title:  Firefighter Cancer Prevention in Denmark and Europe


Authors: Tommy Kjaer


Submitting Author Affiliation: Firefighters Cancer Association, Denmark


Learning Objectives: Identify the best practice to avoid cross contamination after a fire and in the fire house. Demonstrate the state of the art fire suits for better protection against PAH. Describe the best way to clean and decontaminate contaminated gear. Discuss best possible practice in your fire service. Compare this knowledge with your own working environment and rethink if any changes are needed.



Background: Firefighters are exposed to toxic substances when fighting fires such as Polycyclic Aromatic Hydrocarbons (PAHs) and Volatile Organic Compounds (VOCs). Many of them grouped by IARC as known cancer causing for humans Group A. Studies show an elevated risk for certain cancers in firefighters due to absorption through the breathing and digestive systems as well as dermal uptake. In order to bring down firefighters exposure and the exposure time it is necessary to implement prevention in many ways. Preventive work in firefighting is a focus in fire services all over Europe. Methods: In Europe we have developed best practices from the moment the firefighter goes on duty until they goes off duty after a shift. We also cooperate closely with manufacturers of PPE and decontamination systems in order to push for even better protection. Results: BFC has developed practices based on a combination of science, what is practically possible and what is the best known technology in order to bring down cancers in firefighting. This includes:

  • Always avoid cross contamination.

  • Building of clean firehouses.

  • Good behavior on the fire scene using breathing apparatus and definition of “safe zone”.

  • Handle contaminated equipment separately from clean not used equipment with special trucks made for this purpose.

  • Proper cleaning and decontamination after every fire using LCO2 and Ozone.

  • Proper personal washing hygiene after every fire intervention.

  • Healthy living and work out.

  • Develop education programs for fire academies. And training programs for “old” firefighters.

Conclusions: Future studies need to address other issues under suspicion of creating health problems such as interrupted sleep and psychological impacts. Areas where preventive measures should be prioritized even more. Reaching the goal of producing less cancer sick firefighters it’s important for scientists, politicians and firefighters to work together.

Title:  Evaluation of long-term fire effluents hazards to firefighters (2018-2021)


Authors: Ellen Goudsmits, Anna Clinton, and Anna Stec


Submitting Author Affiliation: University of Central Lancashire, Preston, England, UK


Learning Objectives: Analyze, evaluate and discuss exposure of firefighters to carcinogenic toxicants. Identify exposure and metabolic routes for toxicants.



Background: There have been concerns, particularly in the US and Canada that fire effluents may have adverse health effects. The University of Central Lancashire has been asked by the Fire Brigade Union to assess if these concerns apply to UK firefighters, and to develop best practice for minimizing the risk of fire effluent contamination.  The project will look at the exposure routes for fire effluents and other potential contaminants, via screening of firefighters’ work environments and monitoring exposure and contamination during fires. Methods: This research project is set to run for three years, with intermediate reports being released over the full duration. In order to ensure the study produces representative results, 15 UK fire stations will be specifically selected to participate. The investigation will include both emergency incident fires as well as those from training events where a variety of fuels and extinction methods can be studied. Atmospheric monitoring of gaseous and particulate matter will be supplemented by wipe samples taken from equipment and skin. The project is divided into three main areas;

  1. Identification of potentially harmful components within fire effluents, soot deposits and residues.

  2. Evaluation of decontamination methods and equipment damage - influence of different cleaning processes, age and wear on permeability and retention of contaminants.

  3. Evaluation of potential exposure routes - inhalation, ingestion and dermal absorption.

Results: Identification of the contaminants and their routes of exposure will allow for the optimization of decontamination methods for firefighters, their clothing and work environments. Subsequent work, including health screening, will allow for further optimization and development of prevention methods. Conclusions: The outcome is to provide national guidance that will provide recognition of the fire hazards to firefighter health, increase awareness and provide the best practice in minimizing exposure to the most common chronic fire effluents.



Title:  Overview of current practice and awareness surrounding contaminants and decontamination in UK fire stations


Authors: Anna Clinton, Ellen Goudsmits, and Anna Stec


Submitting Author Affiliation: University of Central Lancashire, Preston, England, UK


Learning Objectives: Evaluate current practices in the UK with regards to contamination of PPE and ambient workspaces. Formulate a best practice policy for the Fire Brigade's Union.



Background: It is well documented that firefighters are exposed to carcinogenic substances both during firefighting activities, and from their ambient workplace environments. There is a substantial amount of data from studies carried out in the US and Canada on firefighters and their health, however in Europe only recently have studies been carried out in Nordic countries showing that firefighters have higher rates of cancers when compared to the general population. The objective of this study was to carry out a survey of firefighters at stations across the UK to gain a comprehensive understanding and overview of the current practices used in UK fire stations with regards to decontamination, storage of PPE, and awareness of the health effects of contamination. Methods: A survey was distributed to approximately 30 000 firefighters across the UK. The survey was broken down into sections to determine the individuals’ demographic and activity within the service; variations in provision, use, cleaning and storage of PPE; variations in workplace environment; approaches to personal hygiene; and awareness with regards to potential contaminants. Results: Responses to the survey will be obtained and analyzed within the next two months. It will be analyzed for trends in practice and awareness across the country, employing statistical data analysis. Conclusions: This survey will be implemented in a 3 year research project working to help shape “best practice” in fire stations/workplaces across the UK. This will ultimately help to reduce exposure of personnel to excessive amounts of contamination. 



Title:  Cancer and Disease Mortality Rates for Firefighters in Scotland: 1996-2017


Authors: Louis Turrell, and Anna Stec


Submitting Author Affiliation: University of Central Lancashire, Preston, England, UK


Learning Objectives: Evaluate the risk of benign and malignant diseases in firefighters. Analyze the exposure-response characteristics in firefighters. Compare the disease and cancer mortality incidence in firefighters to that of the general population within the same age distribution for Scotland.



Background: Fire effluents contain a cocktail of toxic, irritant and carcinogenic species, which vary depending on the fire scenario; the specific materials burning and the fire conditions at the incident. Repeated exposure to chronic toxicants, with genotoxic and carcinogenic effects, are of particular concern for firefighters. Regardless of the specific materials burning, carcinogens such as benzene, polycyclic aromatic hydrocarbons (PAHs) and toluene are released in almost every single fire within both the smoke and the soot produced, while the release of halogenated polychloro- and polybromodibenzo dioxins and dibenzofurans, respiratory sensitizers such as isocyanates, and heavy metals (e.g. lead and cadmium) is strongly related to the fire scenario. This study is one of the largest linkage cohort studies evaluating the risk of benign and malignant diseases in firefighters, and the first with adequate statistical power for detailed examinations of the exposure-response characteristics. The disease and cancer mortality incidence in firefighters is compared to that of the general population within the same age distribution for Scotland. Methods: The firefighter establishment figures for 1996-2017 were obtained via freedom of information (FOI) requests to the National Records department of the Scottish Government (NRS). The general population mortality data was obtained using the NRS online access tool.  Results: The statistical significance and higher risk factors for both cancer and other diseases, based on number of deaths per 1000 firefighters was calculated. The mortality rates for multiple myeloma and skin melanoma are significantly higher amongst firefighters than the general population, while increased rates have also been noted for other cancers and diseases, in particular kidney disease. Conclusions: Further research of the specific fire effluents that contribute to specific cancers and diseases is required, alongside long-term health assessments of firefighters.



Title:  Exposure to fire effluents and its impact on firefighter’s health


Authors: Anna A. Stec


Submitting Author Affiliation: University of Central Lancashire, Preston, England, UK


Learning Objectives: Fire toxicity is dependent on both material and fire conditions. Carbon monoxide is a good indicator of incomplete combustion however, it is not always the major toxicant. Hydrogen cyanide concentrations increase by factors of 10 to 50 with under-ventilation. Irritants (hydrogen chloride, organics and smoke particles) can prevent escape, but carbon monoxide will be recorded as the cause death. Unwanted fires will also produce many more products of incomplete combustion, chronic toxicants, including carcinogens, such as polycyclic aromatic hydrocarbons (PAH), respiratory sensitizers such as isocyanates, and PBT compounds such as polychloro- and polybromodibenzo dioxins and dibenzofurans (PCDD/F and PBDD/F) (“dioxins”) from fuels containing halogens.



Background: The toxicity of fire effluents is known to be the biggest cause of death injury from unwanted fires. Compared with natural materials (wood, leather, etc.), widely used synthetic polymers (derived from oil) burn more quickly; they also generate more smoke and toxic effluents, particularly when compounded with halogenated flame retardants. Methods: Lethal fires often involve smouldering furnishing (bed or chair) where there is a gradual increase in the local concentrations of smoke and toxic gases. During this time carbon monoxide (CO) and a large number of organic products are generated in the smoke. This can incapacitate victims or put them into a deep sleep so they do not escape. Once flaming starts, these products of incomplete combustion are oxidised to carbon dioxide and water, and the effluent toxicity of the well-ventilated fire decreases briefly. Fire quickly grows then until the availability of oxygen is limited (under-ventilated). This results in an increase in smoke, reducing visibility as the asphyxiant (oxygen depriving) gases (CO, and hydrogen cyanide (HCN)); irritant gases (hydrogen chloride, hydrogen bromide, acrolein etc.); and deep lung irritants and particulates are generated. CO and HCN concentrations increase by factors of 10 to 50 with under-ventilation, are far more dangerous than the lack of oxygen, and untenable conditions rapidly develop. Unwanted fires will also produce many more products of incomplete combustion, including particulates, carcinogens, such as polycyclic aromatic hydrocarbons, respiratory sensitizers such as isocyanates, and persistent, bioaccumulative and toxic compounds such as polychloro- and polybromodibenzo dioxins and dibenzofurans (PCDD/F and PBDD/F) (“dioxins”) from fuels containing halogens. Results & Conclusions: The effects of fuel (various polymers, building products etc.) and fire conditions will be shown, providing a generic understanding of the release various acute and chronic fire effluents and their effect on firefighter’s health.



Title:  Cancer prognosis by detection method in Korean firefighters


Authors: Kyoung Sook Jeong, In Dam Cho, and Jaehee Lim


Submitting Author Affiliation: Hallym University Sacred Heart Hospital, Anyang, Republic of Korea


Learning Objectives: Compare the prognosis and stage by chances of cancer diagnosis in firefighters. Discuss which cancers should be screened in firefighters.




Background: Firefighters are exposed to many carcinogens including benzene, 1,3-butadiene, polyaromatic hydrocarbon, diesel engine exhaust, shift work and so on. In general, cancer screening reduces the burden of cancer. It is necessary to decide which cancers are screened in firefighters. We compared the prognosis and stage by detection method of cancer in Korean firefighters. Methods: We registered cancers in Korean firefighters. We collected age, year of diagnosis, stage at cancer diagnosis, current status of cancer, employment year, shift work duration and longest job as firefighters, and so on. We compared the stage and current status of cancers by the chances of cancer diagnosis by chi-square test. Results: Total 323 firefighters registered cancers. The mean age and employment duration as firefighters were 42.9 (Standard deviation (SD) 8.52) and 15.5 (SD9.01) years, respectively. Thyroid cancer was most common (108 cases) and the stomach, colorectal, and lymph-hematopoietic system were registered 54, 35, and 31 cases, respectively. 71.6% was detected by health examination and 23.1% was diagnosed during evaluation for clinical symptoms. The death rates were 1.3% in detection cancers by health examination and 12.2% after clinical symptoms. (p=0.03) 16.4% and 54.5% were 3 and 4 stages, respectively. (p<0.001) The cancer stages and death rates were no differences by age, shift work duration, and longest job duration. Conclusions: Health examination is contributed to the good prognosis in firefighters’ cancer. We should study which cancers should be screened in firefighters in the future. This study was supported by Korea Fire Officials Credit Union.




Title:  Development and measurement properties of a firefighter-specific work limitations scale


Authors: Joy MacDermid


Submitting Author Affiliation: Western University, Ontario, Canada


Learning Objectives: To describe the development and psychometric properties of a new firefighter-specific work limitations questionnaire.




Background: Previous validation of a generic Work Limitations Questionnaire tested in firefighters indicated problems with floor effects’ likely arising from the unique and challenging nature of firefighting work. Objective: To develop a firefighter-specific work limitations questionnaire using a mixed-methods approach. Methods: Item generation included a series of interviews: 21 firefighters (15 males, 6 females) from fire services across Canada (Alberta, British Columbia, Nova Scotia, Ontario, Prince Edward Island, Quebec) were interviewed using a semi-structured guide to assess areas of work limitation. The phone interviews were recorded and transcribed verbatim. Content analysis identified 5 themes: physical, social/interpersonal, cognitive, emotional, routines/time management. In addition, we conducted two nominal group exercises with 20 firefighters at a provincial firefighter conference. Items were generated from the firefighter interviews/nominal activities and categorized into the 5 domains. A group of 53 firefighters completed a content analysis survey evaluating the relevance of the items and the frequency with which they were performed. From this analysis, items were classified as strong potential, questionable, or not appropriate. The strong and questionable items were further reduced and clarified by a panel of expert measurement experts working with firefighters. Results: A beta version of a firefighter at-work limitations questionnaire was developed with five subscales, each subscale containing 3 to 6 items. Firefighters endorsed the new measure as relevant to their work. Content validity index for a subset of items and the resulting overall scale was high (> 80%). Additional psychometric properties of the questionnaire are underway and will be presented. Conclusion: A firefighter-specific work limitations questionnaire was developed and will provide a mechanism for more accurate assessment of work limitations across a variety of health conditions (e.g., cancer) affecting firefighters. This type of instrument can also be useful in identifying early concerns with job abilities or planning return to work.

Title:  Stability of wipe sampling for Semi-Volatile Organic Compounds and Polycyclic Aromatic Hydrocarbons from Firefighter's Skin and Clothing


Authors: Kathryn Dickens, Anna Stec, and Marielle Salden


Submitting Author Affiliation: University of Central Lancashire, Preston, England, UK


Learning Objectives: Evaluate literature methods for wipe sampling. Identify best practise for wipe sampling to ensure reliable, stable results. Formulate plans for monitoring contaminants on firefighter's skin and clothing.



Background: Wipe samples are commonly taken from firefighters’ skin and PPE, as well as workplace surfaces. Throughout the literature there are numerous methods employed for collection of samples, with the use of different solvents, materials and analytical technique. This makes it difficult to compare results across different studies. The aim of this study was to optimize a method for wipe sampling which would give the greatest uptake of volatile organic compounds (VOC) and polycyclic aromatic hydrocarbons (PAH) combined with stability. Ultimately, this should improve the reliability of future sampling of this nature. Methods: Wipe samples were taken from skin and surfaces using a wipe impregnated with isopropyl alcohol. Different methods were tried and optimized. Three wipes were taken each time, and these were analyzed using GC-MS at three time intervals from sampling; immediately, 24 hours and 48 hours later. The intervals were chosen to represent possible logistical timescales between sampling and testing. The wipes for delayed testing were stored in sealed amber vials wrapped in foil in a dark place at two temperatures, ambient and refrigerated at 6°C. Results: Wipe samples were found to be stable for 24 hours when stored at ambient temperature. After 48 hours, a number of compounds that were present in earlier analysis were no longer detectable, however benzo[a]pyrene and fluoroanthene remained stable for a longer period of time. When wipe samples were stored in a refrigerated environment, neither PAH nor VOC were seen to decrease significantly after 24h. Conclusions: Storing the samples in air-tight refrigerated conditions is essential for sample stability. Research is continuing into the longer-term stability when refrigerated and into other methods which may provide greater stability.




Title:  Evaluating Causation in Epidemiological Studies of Firefighters


Authors: Tee Lamont Guidotti


Learning Objectives: Describe the standard of certainty in workers' compensation to which experts are held. Describe four common interpretive issues encountered in assessing causation in firefighters. Describe the epidemiological principles behind presumption as a policy.


Background: The evaluation of causation in cancers associated with firefighting presents problems in causality common to other applications of occupational epidemiology in adjudication of individual claims for workers’ compensation. A global trend to establish legislated presumptions for compensation of firefighters has created an opportunity to reevaluate the literature applying standards of certainty based on  the “weight of evidence” (“50% + 1”) rather than elusive and, for many cancers, unattainable scientific certainty. Such standards are the norm and are required to be used in workers’ compensation, which is also required to take into account individual factors. Methods: We have exhaustively and repeatedly reviewed the epidemiological literature (to which we have also contributed) on cancer risk among firefighters based on the weight of evidence rather than scientific certainty. Generalizable frameworks were formulated to define recurrent issues in assessing the evidence from epidemiological studies. Results: We have identified four analytical frameworks describe the problems in analysis encountered:

  1. Rare cancers. “Rare” (in biostatistical sense) cancers are prone to inadequate statistical power in individual studies (e.g. testicular). Misguided response is usually to aggregate cancers into biologically meaningless groups for analytical convenience (e.g. “non-Hodgkin lymphoma”).

  2. Aggregation, one tumor type dominates. Dilution of the risk estimate by misclassification bias introduced by aggregation into rubrics (e.g. brain, when Grade 4 astrocytoma, “glioblastoma”, is the tumor of interest at 34% of total). Elevation in tumor type of interest is easily missed.

  3. Aggregation, no one type dominates.  Epidemiological studies tend to promote illogical groups (e.g. “leukemia, lymphoma, and myeloma”). Elevation in tumor type of interest is diluted and variable among studies.

  4. Potential confounding by smoking. Fletcher has provided a method for correcting for smoking prevalence. By this method, contribution to risk of lung cancer in a non-smoking firefighter could be 

 Conclusion: Epidemiological studies do not, by themselves, answer all the important questions about the etiology (cause) of occupational disease that are required to make a judgment for compensation. They inform conclusions about “general causation”, which refers to evidence for an elevation of risk and the connection between disease and possible causes in general. Workers’ compensation and other compensation systems require individualized evaluation of each case, called “specific causation”, taking into account the individual circumstances, risk factors, and health risks for the claimant. Epidemiology can also inform specific causation by indicating whether risks are disproportionately elevated in certain job assignments, after a certain number of years of exposure, or against a background of other, non-occupational risks (such as cigarette smoking). This requires interpretation.

Title:  Association of inflammatory markers with firefighters activity and sleep disorder in Korean firefighters: a cross-sectional study


Authors: Kanghyun Um, Tae-Won Jang, Yeon Soon Ahn, Chang Sun Sim, and Kyoung Sook Jeong


Submitting Author Affiliation: Hallym University Sacred Heart Hospital, Anyang, Republic of Korea


Learning Objectives: Evaluate relationship with shift work related sleep disturbances and inflammatory markers in firefighters. Evaluate job (fire suppression, rescue, fire investigation) and inflammatory markers in firefighters.




Background: Firefighters are exposed to various harmful factors such as exposure to fire and shift work. There is a study that reported an increase in TNF-α and IL-6 levels after exposure to high temperatures in firefighters and a meta-analysis of sleep disturbances, sleep duration and inflammation markers has shown a link between sleep disturbances and CRP and IL-6. We evaluated the relationship with shift work related sleep disturbances, job (fire suppression, rescue, fire investigation) and inflammatory markers (CRP, TNF-α, IL-6 and GM-CSF). Methods: 516 firefighters randomly sampled from fire departments in Korea were surveyed about sociodemographic and occupational characteristics. Blood was collected from 411 firefighters for inflammatory markers. In shiftwork firefighters, we measured twice each before and after shiftwork. Insomnia severity index and the Epworth sleepiness scale were measured for sleep disturbances. CRP, IL6, TNF-α and GM-CSF in each group were compared. Results:  There was no significant difference in CRP, IL-6, and TNF-α before and after work, and by firefighters’ activity. In the analysis with sleep disorders, only excessive daytime sleepiness (EDS) group showed higher GM-CSF level compared to normal group. The concentration of GM-CSF was correlated to presence of EDS after adjustment for confounding factors (β=0.217, 95% CI=0.005~0.4283, p < 0.05) Conclusion: There was positive relationship with excessive daytime sleepiness with GM-CSF. GM-CSF may be biological marker for EDS. This research was supported by the Field-oriented Support of Fire Fighting Technology Research and Development Program funded by National Fire Agency.



Title:  Association of FGF-23, klotho, and serum 25-OH Vitamin D with shift work in Korean firefighters: a cross-sectional study


Authors: Jeehee Min, Tae-Won Jang, Yeon Soon Ahn, Chang Sun Sim, and Kyoung Sook Jeong


Submitting Author Affiliation: Hanyang University, Seoul, Republic of Korea


Learning Objectives: Evaluate association of FGF-23, Klotho, and Vitamin D concentration with shift work in Korean firefighters.



Background:  Shift work is known to disrupt the human circadian rhythm and risk factor for sleep disorder, metabolic syndrome and cancer. International Agency for Research on Cancer (IARC) classified shift work as a group 2A carcinogen in 2007. Recent studies found that circadian clock gene controls circadian oscillators in molecular level and may acts as tumor suppressor gene. Fibroblast growth factor-23 (FGF-23) regulating phosphate homeostasis is cancer related gene, which mutation may promote cancer progression. Klotho that making complex with FGF-23 is known as tumor suppressor gene. Homeostasis of phosphate concentrations was regulated by FGF-23, klotho and Vitamin D feedback loop. Previous studies consistently reported that elevated FGF-23 and decreased Vitamin D were related to cancers. However molecular pathogenesis of cancer and shiftwork was not clarified yet. In this study, we evaluated the association of FGF-23, Klotho, and Vitamin D with shift work in Korean firefighters. Methods: The subjects were 483 firefighters in six fire stations in Korea. We performed questionnaire survey including sociodemographic and work-related characteristics. The subjects' blood was sampled for measuring Vitamin D, FGF-23, and Klotho. Simple and multiple linear regression analyses were performed with VitD3, FGF-23, and Klotho as dependent variables. Results: The concentrations of alpha-klotho and FGF-23 were correlated to shift work after adjustment for confounding factors (β=0.478 (95% CI=0.002~0.955), β=-1.825 (95% CI=-2.747~-0.903), respectively). However, VitD3 did not show a significant relationship with shift work (p > 0.05). Conclusion:  We found that FGF-23 had a positive relationship, and Klotho had a negative relationship with shift work. For monitoring impact of shift work, alpha-klotho and FGF-23 may be potential biomarker. This research was supported by the Field-oriented Support of Fire Fighting Technology Research and Development Program funded by National Fire Agency.



Title:  The National Fire Operations Reporting System


Authors: Lori Moore-Merrell and Craig Weinschek


Submitting Author Affiliation: George Washington University, Washington DC, USA


Learning Objectives: Describe the National Fire Operations Reporting System (NFORS) Exposure App

List the data elements captured by the App. Demonstrate the NFORS Exposure App to others. Discuss methods of on-boarding firefighters to the system and accessing data for analysis.




The National Fire Operations Reporting System (NFORS) uses technology to capture data from computer aided dispatch (CAD) systems or records management systems (RMS) and analyze that data to provide operational insights for chief officers and the rank and file. At the policy making level, NFORS is a fire service analytical system and the most comprehensive way to get accurate and real-time information to help fire service leaders assure adequate fire resources; optimize fire operations; reduce firefighter injury and death; minimize civilian injury and death; and minimize property loss. NFORS does more than just report the details of the incident, it digs deeper into the operations to provide a richer and fuller analysis.  NFORS asks, “What was the environment like when fire fighters arrived? What did fire fighters do, what was the engagement with the fire? What toxic materials were encountered?” To the fire officer, firefighter and paramedic responding to emergency incidents, NFORS is also a personal database providing a detailed history of their work and exposures in a private, encrypted, secure online environment, all available on a mobile device. The NFORS Exposure App becomes a firefighter career diary to assure evidence of career exposures, should physical or behavioral health issues arise long-term or even in retirement. As more governments enact presumptive legislation providing worker’s compensation coverage for firefighters who get cancer, the NFORS Personal Exposure Record will help provide the necessary evidence to show work related exposure. Today many firefighters struggle to gather the evidence that on-the-job toxic exposures are linked to their cancer. Now all the information can be stored in one place. NFORS is engaged with departments throughout the U.S. and with the CDC and NIOSH on studies tracking firefighter exposures.  NFORS can be the tool to assure data consistency for other researchers as well.



Title:  FASNY-- Northwell Health Study of Cancer in Volunteer Firefighters in New York State (NYS): Research in Progress


Authors:  Jacqueline Moline, Anne Golden, Gina Arena, Vincenza Caruso, Brittany Hobbie, Charles Purcell, and Brian McQueen


Submitting Author Affiliation: Northwell Health, New York, USA


Learning Objectives: Understand why data on volunteer firefighters’ cancer incidence and mortality (overall, cause specific) is needed in addition to what is known from studies of career firefighters. Describe the methods used in this study for recruitment, data collection, and determining how patterns of cancer incidence and mortality among volunteer firefighters in New York State compare to risks in the general population and among career firefighters. Consider how risk factors at the individual level and at the fire department or community level may be associated with increased cancer incidence and mortality among volunteer firefighters.




Background: Carcinogen exposures place firefighters at an increased risk for developing certain kinds of cancers; however, cancer incidence data is only available in the United States (U.S.) for career firefighters. Of the estimated 1.1 million firefighters in the U.S., over 70 percent are volunteers. The largest cohort study to date of career firefighters, conducted by the National Institute for Occupational Safety and Health (“the NIOSH study”), found increased risks for cancer overall and in the respiratory, digestive and urinary systems. Evidence for career firefighters may not be applicable to volunteers due to varied intensity and amount of exposure.  The Firemen’s Association of the State of New York (FASNY) is sponsoring the first large-scale all-volunteers study in the U.S. to determine cancer incidence and mortality rates and examine factors associated with increased cancer risks among volunteer firefighters. Methods: Over 1,700 volunteer and combination fire departments in NYS were eligible to participate in the study. Participating fire departments complete a survey with departmental and training event information and submit rosters of past and present members that include name, birthdate, address, and service details. The Office of Fire Prevention and Control (OFPC) provided 2012-2016 fire run reports for every NYS fire department. Results: Enrollment will end in May, 2019.  Data on recruitment strategies and participant characteristics will be presented. Conclusions: The final study roster will be submitted in late 2019 for linkage analyses with state cancer registries and the National Death Index. Cancer incidence and mortality in the study population will be compared to expected rates based on NYS and U.S. populations. Departmental factors, including fire runs, will be used to assess community-level exposure indices and evaluate whether exposures from firefighting in the volunteer fire service contribute to increased risks for certain cancers seen in comparable studies of career firefighters.

Title:  Roadmap to Establishing a Firefighter Cancer Initiative Prevention and Wellness Clinic


Authors:  Michelle Penaranda, Johanna Garibaldi, Maritza Alencar, Jessica MacIntyre, and Erin Kobetz


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: Discuss the process of establishing a firefighter cancer prevention clinic.

Identify cancers and risk factors that are unique to the firefighter population. List the key steps needed to launch a firefighter specific clinic. 



Background: Firefighters have chronic exposure to carcinogenic materials and chemicals. Carcinogens such as benzene and polycyclic aromatic hydrocarbons (PAHs) are present in active burning fires1. This exposure over time has raised concerns about possible occupational associated cancer risks. According to a retrospective cohort study done by Ma, et al (2006), which focused solely on firefighters in the state of Florida, increased findings for cancer included:

  • Bladder

  • Thyroid

  • Testicular

  • Cervical

The Firefighter Cancer Initiative (FCI) launched in 2015, with the purpose of understanding cancer in the firefighter population. As part of ongoing research, the Cancer Prevention and Wellness Clinic was created to provide prevention, screening and early detection of cancer to active and retired firefighters. Objectives: To describe one institution’s roadmap to establishing a Cancer Prevention and Wellness Clinic.

Interventions: Steps to launch the clinic involved:

  • Hiring clinic personnel

  • Collaboration with various departments such as marketing, IT, and other key stakeholders

  • Meeting with local fire departments to advertise the clinic in the community

  • Establishing clinic guidelines and intake processes 

  • Developing in-services for clinic nurses

Discussion: Firefighters in the community have yearly physicals as a job requirement. If results from their yearly physical are suspicious for cancer, firefighters have no designated specialists for follow up. The purpose of this clinic is to provide an all-inclusive service to include comprehensive exams, diagnostic tests when applicable, referral to specialists and follow up as indicated all within one established comprehensive cancer center. Conclusion: As the clinic grows, the goal is to help further our understanding of screening practices, as well as, create a national standard of care for cancer screening among firefighters. The added benefit for the firefighter population is the availability of clinic trials offered by the center with ongoing collaboration with the FCI research team.  

Title:  Firefighters exposures to polycyclic aromatic hydrocarbons and other environmental mutagens during emergency fire suppression


Authors:  Jennifer Keir, Umme Akhtar, David Matschke, Paul White, Tacy Kirkham, Laurie Chan, and Jules Blais


Submitting Author Affiliation: University of Ottawa, Ontario, Canada


Learning Objectives: Define cancer rates in the fire service. Explain how exposures to chemicals may influence one's risk of developing cancer and other illnesses. Explain, with data to back it up, how firefighters are exposed to chemicals during emergency fire suppression. List actions that can be taken to reduce firefighters' exposures to toxic chemicals while on-shift.




Background: Firefighters experience above average risks of cancer and other serious illness. Their exposures to combustion emissions, including polycyclic aromatic hydrocarbons (PAHs), metals, and other products of combustion are a concern. Few studies have examined firefighters’ exposures to combustion emissions during on-shift emergency fire situations. Objectives: To assess firefighters’ occupational exposures to combustion emissions during emergency fire suppression. Methods: We measured exposures to PAHs, antimony, cadmium, and lead using (1) personal air samplers worn by firefighters during emergency fire suppression; (2) wipe samples of skin, personal clothing, and personal protective equipment (PPE) collected before and after emergency firefighting; and (3) urine samples collected before and after emergency firefighting. We examined chemical exposures in firefighters by measuring PAHs and metals in air and surface wipe samples of skin, clothing, and PPE. We determined urinary PAH metabolite concentrations and urinary mutagenicity using the Salmonella mutagenicity assay (Ames test). Urinary Clara Cell 16 (CC16) and 15-isoprostane F2t (8-iso-PGF2α) concentrations were used to assess lung injury and oxidative stress, respectively. Results: Air concentrations exceeded occupational exposure limits at two fire events for lead and nine for PAHs. After fire suppression, PAH concentrations were significantly higher on skin and PPE (p<0.001), antimony on skin, clothing, and PPE (p<0.001, 0.01, and 0.05, respectively), and lead on skin and PPE (p<0.001). Post-event concentrations of urinary PAH metabolites were, on average, 2.9- to 5.3-fold higher than pre-event values, depending on the PAH metabolite (p < 0.0001). Average post-event urinary mutagenicity showed a significant, event-related 4.3-fold increase (p < 0.0001). Urinary CC16 and 8-iso-PGF2α did not increase. PAH concentrations in personal air and on skin accounted for 54% of the variation in fold changes of urinary PAH metabolites (p<0.002). Conclusions: The results indicate that emergency, on-shift fire suppression is associated with significantly elevated exposures to combustion emissions.

Title:  Perceived Health Risks Among Firefighters; A Survey of the New Jersey Firefighters


Authors:  Sean Maloney, Michael B. Steinberg, Taylor M. Black, Iris R. Udasin, Courtney H. Tilton, Michael E. Pratt, and Judith M. Graber


Submitting Author Affiliation: Rutgers University, New Jersey, USA


Learning Objectives: List the broad categories of disease firefighters attribute additional risk to as a result of their employment. Discuss the importance of understanding both the clinically significant threats to firefighter health as well as firefighter’s perception of those threats. Identify knowledge gaps in firefighter preparatory programs and evaluate barriers to addressing them.



Background: Firefighting is an extremely dangerous occupation, placing firefighters at increased risk of injury, illness, disability and death. While literature on health risks of firefighting, including excess cancer, is extensive, little information exists regarding firefighter’s perception of these health threats. We assessed the level of additional risk current and former firefighters attribute to disease onset as a result of their employment. Methods: Firefighters attending an annual union convention were asked to complete a paper survey. The survey consisted of four domains: demographics / risk behaviors, cancer screening history, firefighting experience (duration of firefighting career/volunteer work) and a 6-point Likert scale assessing additional risk for disease (“0” representing “no additional risk” and “5” representing “a lot of additional risk”). Medians and standard deviations of perceived risk were calculated for each health condition, and all cancers combined. Occupational and demographic risk factors of perceived risk were assessed in bivariate and multivariable analysis. Results: Of 169 completed surveys one was excluded due to missing data (n=168). Firefighters were predominately male (99%), non-Hispanic White (76%) and 74% had at least some college education. Most were overweight (BMI >25 and <30: 42%) or obese (BMI >30: 47%). Firefighters median perceived risk ranged from 4.0 (colon, hematologic, breast, prostate and testicular cancers) to 5.0 (cardiovascular diseases, pulmonary diseases, all cancers, lung and oral cancer). Conclusion: New Jersey Firefighters attribute “a lot” of additional risk to acquiring various diseases (cardiovascular and pulmonary diseases, any kind of cancer) as a result of their employment. With a firm understanding of the most clinically significant threats to firefighter health and wellbeing, gauging active duty firefighter perception regarding their own morbidity and mortality will help develop future firefighter education and preparatory programs. Future implementation of this survey will be conducted to inform firefighter cancer screening practices.



Title:  Skin Cancer Screening Using Total Body Photography and Digital Dermoscopy: A Pilot Study Among Firefighters in Florida


Authors:  Rachel Fayne, Valeria De Bedout, Mahtab Forouzandeh, Joshua Fox, Mina Zarei, Alyx Rosen, Claudia Genaro, Lilia Fernandez, Feng Miao, Natasha Solle, Alberto Caban-Martinez, Tulay Koru-Sengul, Robert Kirsner, and Natalia Jaimes


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objectives: To determine the feasibility and diagnostic accuracy of TBP and digital dermoscopy (DD) as a triage alternative to the initial face-to-face full body skin examination (FBSE) skin cancer screening (SCS) among Florida firefighters.



Background: Early detection of skin cancer remains the most cost-effective means of improving outcomes and reducing associated costs. Dermoscopy and total body photography (TBP) are non-invasive tools that improve early detection, especially for high-risk individuals such as firefighters. Objective: To determine the feasibility and diagnostic accuracy of TBP and digital dermoscopy (DD) as a triage alternative to the initial face-to-face full body skin examination (FBSE) skin cancer screening (SCS) among Florida firefighters.

Methods: Cross-sectional observational study with a diagnostic test and concordance analysis. Miami-Dade firefighters 18 years or older were eligible for inclusion. SCS were performed by 2 dermatologists and 2 dermatology residents over three days. Participants underwent FBSE by a physician and TBP with DD performed by a non-dermatologist. A physician, blinded to the FBSE, reviewed the TBP images. Physicians documented suspicious findings, confidence level, and management decision. Patients documented sun-related behaviors, skin cancer history, and attitudes towards SCS. Suspicious lesions were biopsied on-site. The study was approved by the IRB at University of Miami. Results: Overall,136 firefighters were enrolled with 100% participant survey response rate.  Almost half of firefighters (47.8%) had ever had a FBSE performed by a physician and 38.2% regularly perform a self-skin exam. Although only 1.5% reported having TBP in the past, 97.8% would consider TBP for virtual SCS. From the 136 firefighters, 127 underwent FBSE and TBP (110 males). Physicians reported suspicious lesions in 26.8% (n=34) of FBSE versus 33.9% (n=43) of reviewed images, showing a trend towards more skin cancer diagnoses with TBP.  When FBSE did not reveal suspicious lesions, the physician would reassure in 96.9% of the cases, compared to 54.3% of cases with TBP. Conclusions: Our preliminary results demonstrate an opportunity to improve primary prevention efforts for skin cancer among firefighters. Further studies are needed to validate the clinical utility and cost-effectiveness of TBP for virtual SCS.




Title: Longitudinal Association between Cancer Diagnosis and Engaging in a Secondary Occupation among Florida’s Firefighters: Analysis of the Annual Cancer Survey Cohort Data 2016-2018


Authors: Kemi Ogunsina, Alberto J. Caban-Martinez, Natasha Schaefer Solle, David J. Lee, Tulay Koru-Sengul, Evan Roberts and Erin N. Kobetz


Submitting Author Affiliation: University of Miami, Miami, FL, USA


Learning Objective: Describe the association of second job and cancer diagnosis in a sample of Florida firefighters.





Background: Cancer among firefighters have been associated with their occupational exposures to chemicals and carcinogenic agents. Epidemiologic studies in the U.S. Fire Service suggest that approximately a third of the workforce engages in second jobs that could be contributing other workplace exposures. In this study, using a cross lagged panel model we assessed the longitudinal association between engaging in a secondary occupation and cancer diagnosis among male and female Florida firefighters. Methods: Data from the 2016-2018 Annual Cancer Survey cohort of Florida firefighters was analyzed using a cross lagged panel model to examine the longitudinal reciprocal relationship between engaging in a secondary occupation in the past 12 months and cancer diagnosis in the last 12 months. Series of regression equations were estimated simultaneously controlling for age, gender and education. Results: A total of 244 male and female firefighters, 18 to 65 years old in active service followed up for 3 years (2016-2018) with 9% self-reporting a cancer diagnosis and 69% with a second job. Engaging in a secondary occupation at a prior time is positively associated with both engaging in a secondary occupation (βjob=0.822;p<.0001) and with cancer diagnosis at subsequent time (βjob=0.312;p<.05) but negatively associated at the 3rd time point (βjob=0.216;p>.05). Conclusions:  Firefighters who engage in a secondary occupation are more likely to engage in a secondary occupation subsequently and those who engage in secondary occupation are likely to have a cancer diagnosis at the subsequent time point after which they are no longer at risk.

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