Reducing the Incidence of Cancer Among Firefighters: Jacksonville’s Best Practices

BY TREVOR NELSON

In the fire service, traditions live long and die hard. For years, the fire service has been reluctant to embrace change until the evidence that proves a contrary path is beneficial becomes ingrained into our psyche. One area in which firefighters have been reluctant to modify their approach is that menial but necessary task, overhaul. Because there generally is a lack of heavy smoke and there is no urgency to stop a fast-moving fire during overhaul, firefighters generally remove their personal protective equipment (PPE) and self-contained breathing apparatus (SCBA) to accomplish the task more quickly. We are not fully aware of the unannounced hidden dangers lurking in what appears to be clean air; breath-taking chemicals known as asphyxiants; toxins that irritate lung tissue; and allergens, which, as the name implies, can cause allergic reactions to skin and mucous membranes. The most deadly danger firefighters face, however, is the carcinogens, which can cause cancer years after an exposure.

This article was written to make fire service members aware of these threats, especially in the forms of a higher cancer incidence and mortality rate and twice the rate of mesothelioma than is seen in the U.S. general population. Research substantiates these claims and reinforces that we need to better protect ourselves by adopting revolutionary best practices that will change how we perform overhaul.

The Jacksonville (FL) Fire and Rescue Department (JFRD) has committed to this action. Following are the “why” and “how” we have been motivated to move out of the “cancer game.”

CULTURE CHANGES

Experience, as usual, has been the greatest teacher and motivator.

• SCBA. On August 6, 1970, a fire occurred at an A&P supermarket on the west side of Jacksonville. Lieutenant Newton “Eugene” Johnson was overcome by heat and smoke after the roof collapsed; he subsequently died of anoxia. He had been wearing a canister mask. JFRD members had been comfortable with using canister masks. However, the day after this tragic event, Chief John J. Hubbard ordered that the canister masks be removed and replaced with SCBA, the accepted standard and highest level of protection used nationwide. Sadly, as in most incidences, it took a tragic event to change the culture of our department.
• Infection control. Ingrained in our culture was the “badge-of-honor” concept. When the JFRD began providing fire service-based emergency medical transport service in the nation in 1967, the “badge” was blood on a white uniform shirt. It was thought to illustrate, like grease on a mechanic’s shirt, that one was not afraid to get dirty, to complete the task. Once the issues with bloodborne pathogens began to become apparent, there was a paradigm shift in the JFRD: All bodily fluids were handled with nationally recognized universal infection-control precautions.
• PPE. Another “badge of honor” has been associated with a soot-, smoke-, and contaminate-laden helmet and PPE-“proof” that the firefighter was not afraid of being on the front lines and in the midst of the hottest of the battle. But, another cultural change is looming! Many scientific studies have shown that these contaminates that linger on our gear can cause cancer long after the firefighters have left the fire scene. The same gear/SCBA that protects us from these hazardous materials on the fireground can expose us to the same dangerous materials when the firefight is over.

EDUCATION: RESEARCH FINDINGS

Another motivator for moving toward better health and away from cancer has been education, especially research study findings.

Cancer and Toronto, Canada, Firefighters¹

The first study that revealed a higher incidence of cancer in firefighters was published in 1992. The participants were firefighters from Toronto, Canada. Although the study was originally undertaken to track cardiovascular disease, its greater impact was associated with the findings concerning firefighters and cancer.

“Statistically significant excesses were seen in the study population of firefighters in comparison with the general U.S. population for cancer of the brain and other nervous system tumors and ‘other’ malignant neoplasm.” It noted the following:

There are also suggestive increases in risk for several other causes of death, including various cancers, and diseases of the respiratory, circulatory and digestive systems. For several causes of death, we have argued that because fire fighters are selected for their excellent health, where moderate increases are apparent compared to the general population, these are probably underestimates of the magnitude of the true hazards of firefighting.

Some of the interesting statistics from this three-year study follow:

• Of 5,414 employees, 837 deaths were reported. Sixty of these deaths were excluded for various reasons.
• Of the remaining 777 deaths, 29 percent occurred in current workers or within one month of termination (retirement) of employment, 61 percent occurred more than two years after termination (retirement), and the remaining 10 percent between these two intervals.
• The mean age at death was 63 years old.

The finding that life expectancy was reduced so dramatically was eye-opening to the fire service community.

Smoke and Phoenix, Arizona, Firefighters²

In the year 2000, the results of a study on the contents of smoke involving members of the Phoenix (AZ) Fire Department (PFD) hazardous materials team were published. The participants were studied over the course of engaging in the overhaul phase of 25 structure fires. The firefighters wore specialized vests that “comprehensively” monitored the air to which they were exposed during these overhauls. The vests were referred to as “Christmas tree vests” by JFRD Chief of the Fire Operations Division Kurtis R. Wilson, who initiated JFRD’s efforts to protect its members from cancer. The vests had warning lights that signaled when contaminates were encountered during the overhaul phase. The alerting of these vests provided the PFD with the information it needed to demonstrate to its members that they were encountering extensive potential threats to their health and needed to take steps to protect themselves during overhaul. The overhaul phase of a fire lasts an average of 30 minutes. During this phase, when there is little or no smoke in the environment, firefighters are most likely to remove their respirator face piece and work in this environment without respiratory protection. A number of studies have identified toxic chemicals in fire smoke, but few specifically associated them with the fire overhaul environment as the Phoenix study.

Essentially, polynuclear aromatic hydrocarbons (PNA), which were hypothesized to be present in smoke but were not visible in the “clean smoke,” as well as 17 chemicals, some known carcinogens, were found in the smoke. Irritants, carbon monoxide (CO), and other chemical asphyxiants were also identified. In four samples, the levels were so elevated that the amount of the substances could not be determined. Respirable dust and asbestos were also found in the “clean smoke.” Moreover, many of the chemicals had combined with soot, thereby making the soot itself cancer causing.

The Phoenix study showed that “concentrations of air contaminants during fire overhaul exceed occupational exposure limits.” It recommended wearing respiratory protection during overhaul and that SCBA be used in atmospheres with CO concentrations above 150 parts per million (ppm); air-purifying respirators (APRs) may be used when CO concentrations are below 150 ppm. The report’s statement that CO concentrations should not be used to predict the presence of other contaminants revolutionized how the fire service started performing overhaul, essentially monitoring for CO and volatile organic compounds (VOC) levels to determine if an SCBA is needed for that environment.

Cancer Risk Meta-Analysis³

In 2006, the results of a review of 32 studies pertaining to firefighters and cancer risk were published. It was revealed that firefighters had a higher likelihood of risk for three types of cancer: multiple myeloma, non-Hodgkin lymphoma, and prostate cancer. The study categorized these as “probable” cancers for firefighters, noting that firefighters had 1¼ to 1½ times higher rates of developing these cancers than the general population. Testicular cancer was shown as “probable” also (two times the rate for firefighters). In addition, the study listed eight additional cancers that had a “possible” association with firefighting.

Another interesting finding of this analysis was that diesel exhaust fumes gather in the apparatus bay and contaminate the living quarters and any bunker gear stored in the apparatus bay. The study also heightened concern about respirable dusts and “building particle debris,” such as those present at the World Trade Center disaster site.

The study also noted the following:

• Soot, a group-one carcinogen, gets absorbed into the body when firefighters sweat through the skin on their faces and hands and under their gear.
• Firefighters aren’t getting adequate protection from absorption of these compounds through their skin.
• Often firefighters return from fires covered in soot and are too tired to shower before they go to bed. “Firefighters should meticulously wash their entire body to remove soot and other residues from fires to avoid skin exposure.”

IAFF and IAFC

The International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) have recognized the dangers firefighters face in these hazardous environments and workplaces. They are fighting for presumptive legislation, which assumes that a firefighter acquires one of these listed cancers on the job and that it should be covered under workers’ compensation.⁴ As generally happens when occupational health hazards are identified, controversy arises among the parties of opposing interests. The National League of Cities hired the Tridata Corporation to create a report.⁵ This study concluded that there was no correlation between these cancer studies and firefighter cancer rates.

NIOSH, USFA, CDC⁶

Fire service organizations then turned to the government agencies responsible for the public health to resolve the difference of opinion. The National Institute for Safety and Health (NIOSH), along with the United States Fire Administration (USFA) and the Centers for Disease Control and Prevention (CDC), called for a study. The USFA and NIOSH partnered on a formal epidemiological study with medical oversight to clarify the relationship between firefighter occupational exposures and cancer. The study yielded more precise disease risk estimates. The study group was significantly larger than those of previous studies (30,000 firefighters from three large cities-San Francisco, Chicago, and Philadelphia) and employed a more detailed exposure surrogate metric in the mortality and incidence analyses than those studies.⁷ The study concluded that this population of firefighters had higher rates of several types of cancers, and of all cancers combined, than the U.S. population as a whole.

Following are some criteria and pertinent findings of this study:

• The participating firefighters had been employed since 1950 and were followed through 2009.
• To ensure validity and reliability, the method examined the “mortality and cancer incidence evaluated by the life table methods with the U.S. population referent.”
• Cancer mortality was 1.14 times higher than that in the U.S. population, and incidence was 1.09 times higher in digestive and respiratory cancers.
• There were “modest elevations of several solid cancers; however, evidence of excessive lymphatic or hematopoietic cancers was lacking.”
• This study was the first to report excessive malignant mesothelioma, which showed an incidence twice as high for firefighters. NIOSH found the connection between firefighters and the incidence of malignant mesothelioma “noteworthy, given that asbestos exposure is a known hazard of firefighting.” (7)
• Firefighters in the San Francisco Fire Department showed a significant increase in bladder cancers.
• Studies had begun in relation to breast cancer, given the increase in the number of female firefighters.

NIOSH concluded that there was “evidence of a relation between firefighting and cancer.”

In the second phase of the NIOSH/USFA study, researchers examined employment records from the same three fire departments in which the participants in Phase 1 were employed to derive information on occupational exposures in relation to cancer incidence and mortality. “This report provides the foundation for subsequent analyses of firefighter risks, some of which are ongoing. In future research, detailed employment histories (numbers and types of fire runs) and institutional knowledge (use of respiratory protection and source capture ventilation of diesel exhaust) will be used to derive exposure metrics to more accurately examine dose response. Expansion and continued follow-up of this cohort would enhance future analyses, particularly among women and non-Caucasian firefighters.” (7)

Smoke Components: Underwriters Laboratories⁸

Underwriters Laboratories’ (UL) study Firefighter Exposure to Smoke Particle (2000) reaffirmed that firefighters are exposed to asphyxiants, irritants, allergens, and carcinogens and noted that they are also exposed to “respirable particles in the ultrafine range (particles less than 0.1 micron in diameter), which have been detected in smoke.”

The study determined the following:

Gaps existed in the knowledge concerning the size distribution of smoke particles generated in fires and the nature of the chemicals absorbed on the particles’ surface. Some gaseous effluents may condense on personal protective equipment and exposed skin, leaving an oily residue or film. These chemicals can pose a significant threat to firefighter health directly (via the skin, the eyes, or by inhalation) or following dermal absorption.

Some of the key findings highlighted in this study include the following:

• 99+ percent of smoke particles collected during overhaul were less than 1 micron in diameter. Of these, 97+ percent were too small to be visible by the naked eye, suggesting that clean air was not that clean.
• Gas monitors would not provide warning for arsenic exposure.
• CO monitoring may provide a first line of gas exposure defense strategy but does not provide warning for fires in which CO does not exceed recommended limits but other gases and chemicals do.
• Multiple asphyxiants, irritants, allergens, and chemicals carcinogenic for various tissues were found in smoke during suppression and overhaul phases.
• Carcinogenic chemicals, including those on contaminated gear, may act topically following inhalation or dermal absorption.
• High levels of ultrafine particles were found during the suppression and overhaul phases, during which exposure to particulate matter has been shown to have a positive correlation with increased cardiovascular morbidity and mortality.
• The high efficiency of ultrafine particles deposited deep into the lung tissue can result in the release of inflammatory mediators into the circulation, causing toxic effects on internal tissues such as the heart.

Cancer Clusters

As was stated earlier, it takes a tragic event to change the culture of the fire service. Prevalent examples involved the Seattle (WA) firefighters and the Wade Chemical Fire in Chester, Pennsylvania. Both examples involve cancer clusters. According to the Seattle Firefighters Pension Board: “Of 975 firefighters hired in Seattle before 1977, about 350 have been diagnosed with cancer, and 43 of the men were younger than 60 when diagnosed.”9

Seven percent (119) of the 1,622 employees who had worked in one station had developed cancer since 1975.¹⁰

At the fire at the Wade Chemical Dump in Pennsylvania on February 2, 1978, firefighters and other on-scene workers exposed to spilled and burning cauldrons of various chemicals had devastating effects. Of the more than 200 workers directly exposed to the warehouse fire, “serious illnesses-cancer, vascular and neuromuscular disorders, and kidney failure-have afflicted at least 45, about one in five.”¹¹ The toll has been devastating. “By early 1988, at least 21 cancers alone were diagnosed among men who worked the fire or its aftermath-men who were, on average, in their mid-40s.” Many chemically induced cancers do not appear for 20 years. At the time this article was written, it was 22 years later, and many of the medical issues were growing:

• Lung cancer hit the group at nearly five times the rate expected in the general public.
• Melanoma, the deadliest form of skin cancer, struck at six times the expected rate.
• Two men walking side-by-side collecting chemical samples during the fire died of amyotrophic lateral sclerosis (ALS) within 14 months of each other; ALS normally affects only two people in 25,000.
• Multiple sclerosis, a one-in-800 disease in the northern United States, plagues two of the group.
• By 1990, three firefighters were on dialysis for kidney failure, a one-in-1,000 condition in the United States. Two have died; the third is seriously ill.
• A vast assortment of other malignancies, blood ailments, and vascular disorders also has occurred. The list includes four colon cancers, three prostate cancers, two brain cancers, two liver cancers, two kidney cancers, three cases of peripheral vascular disease, and single cases of Hodgkin’s disease, aplastic anemia, leukemia, and cancers of the pancreas, esophagus, larynx, thyroid and chest wall. (11)

It was estimated that at the Wade Chemical Dump site, only 2,600 of the more than 20,000 drums that had been stacked at the dump survived intact. Chemicals streamed across the grounds. (11) Many of the chemicals reportedly at the site were known and suspected carcinogens, such as arsenic, benzene, chromium, polychlorinated biphenyls, lead, cyanide, toluene, and mercury.

When we begin to see chemicals such as benzene and toluene involved in structural fires, we need to have a heightened level of concern. A study through Cornell University that links chemical exposure to breast cancer has been cited as an alert to female firefighters.¹² The National Toxicology Program (NTP) has found that the following chemicals are capable of inducing mammary tumors in long-term cancer studies conducted in rats and mice. All of these chemicals can be generated in various fire scenarios: benzene; 1,3-butadiene; isoprene; methylene chloride; 1,2,3-trichloropropane; 2,4-toluenediamine; 2,4-toluene diisocyanate; 2,6-toluene diisocyanate. (11) One-fourth of these cancer-causing chemicals were found at the Wade Chemical Dump Fire.

As noted from the Cornell Web site, the emphasis remains on SCBA usage: “Personal protective equipment, especially SCBA, needs to be worn during all phases of firefighting since there is a potential for exposure to chemicals that may increase breast cancer risk in all types of nonstructural and structural firefighting activities.” (12)

Some other interesting notes about cancer and firefighting include the following:

• During the investigation of the string of church fires that occurred in the South, Bureau of Alcohol, Tobacco, Firearms, and Explosives agents began developing higher levels of bladder cancer (although it is assumed that they were using APRs). The white male ATF agents showed a statistically significant increased risk for bladder cancer in comparison with white males in the U.S. general population for the study period of 1993 to 2007.¹³
• A study conducted by IAFF Local 1403 revealed that of the 246 deaths reported in the Miami-Dade (FL) Fire Department, 63 were attributed to cancers of all types.14 That is more than 25 percent.

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