Investigation of Cancer in Firefighters

The fire service has in recent years begun to introduce several significant studies regarding finding exposure to polycyclic aromatic hydrocarbon (PAH) causing an elevated increase in cancer incidence in firefighters. Studies are targeting the increased rate of cancer diagnosis in firefighters, through testing of personal protective equipment (PPE), equipment, trucks, and facilities. Studies are linking dirty gear to contact exposure of cancer-causing carcinogens. Researchers (Keir, J. L., Akhtar, U. S., Matschke, D. M., White, P. A., Kirkham, T. L., Chan, H. M., & Blais, J. M. 2020) examined cultural change and cancer risk reduction in the fire service with “clean gear as the new badge of honor”. Their research showed that 20% of firefighters in their study currently see dirty gear as a badge of honor (inverse from the historical 80%).

The researcher analysis could impact the understanding of the vital continual need for education and training in the use of cleaning PPE and decontamination of gear. By reviewing the data, the fire service can prevent exposure to carcinogens by recognizing and implementing the cleaning of PPE and impacts at the fire station including storing gear and exhaust control systems. This study will attempt to evaluate the causation of exposure to cancer-causing carcinogens and the link to education and training in the fire service. This will be accomplished by examining surveys distributed to firefighters in Southern Nash County. These stations would include Bailey, Spring Hope, Stanhope, Middlesex, and Ferrell's fire departments. And by studying data gathered to determined the level of education and need for continual education and training in PPE cleaning. This study will attempt to answer the following questions:

• What level of knowledge do active firefighters have of agents that cause an increased risk of incidents of cancer? ·
• What types of cleaning methods are currently being used for cleaning of PPE after fire suppression?
• Our cleaning wipes being provided to begin the personal decon process? Studies show that cleaning wipes can reduce PAH contamination by 54%.
• Are fire stations equipped with direct source control exhaust systems?
• Our industrial washing machines being used after each fire suppression event?
• Where is PPE stored when it’s not in use?
• What type of material is a firefighters hood made from Nomex or another particulate blocking hood?

Hypotheses and Variables

The proposed hypotheses are:

• “Cancer diagnosis will decrease for firefighters within fire departments due to improved technology, education, and training in cleaning and care of PPE and equipment.” The contamination and control of cleaning PPE as well as training and education (independent · variable) will be high in the survey/questionnaire and there will be a positive impact of these factors on the diagnosis of cancer in firefighters (dependent variable).
• “Cancer diagnosis is higher among firefighters, thus the greater probability that someone in the department will be diagnosed with cancer.” Cancer diagnosis (independent variable) will be higher than normal on survey and could lead to a higher probability that a firefighter will die from cancer (dependent variable).

Significance of the Study

This study will provide fire departments with data that will demonstrate the level of training and education that has been completed and what level of continuing education and training needs to be done. It proposes to analyze research on cleaning containments from PPE, storage of PPE, and cleaning of fire trucks as well as other fire suppression equipment. The results will be useful in guiding continue education and training to fire departments to work on decreasing the incidents of cancer diagnosis in firefighters from contaminated PPE. This and other research may lead to life-saving measures for firefighters that put their life on the line saving others.

Literature Review

Risk of Cancer Among Firefighters Sam Youakim (2006), with the Division of Occupational Medicine, indicates that firefighters are exposed to “to a large number of known or suspected carcinogens during their firefighting activity, including benzene, benzidine, 1,3-butadiene, dioxins, dibenzofurans, polycyclic aromatic hydrocarbons, asbestos, formaldehyde, and acrylonitrile.” These carcinogens are linked to cancer in the colon, kidneys, bladder, and brain as well as non-Hodgkin’s lymphoma and leukemia. Youakim (2006), completed a computer search of databases from 1966-2005, he found that an accurate quantitative estimate of firefighter exposure was logistically difficult to obtain. His study used time increments subcohort < 10 years, > 10 years, > 20 years and > 30 years, a fixed-effect model. Youakim (2006) reviewed 6 studies and noted a lack of consensus. Several older published studies validate an increased risk of cancer among firefighters with a level of certainty that work as a firefighter is related to brain cancer. Studies found other cancer malignancies were inconsistent and did not show sufficient evidence. This can be influenced by various factors including different job tasks, and historic changes in firefighting activities. In 2018, the United Kingdom study identified that polycyclic aromatic hydrocarbons (PAH) exposure and studies completed by the National Institute of Occupational Safety and Health (NIOSH) have shown built-up toxins on PPE with repeated use and increased exposure.

Stec, A. A., Dickens, K. E., Salden, M., Hewitt, F. E., Watts, D. P., Houldsworth, P. E., & Martin, F. L. (2018) reported due to environmental component exposure to carbon combustion polycyclic aromatic hydrocarbons (PAH) firefighters have an increased risk of cancer than the general population. This study stated that the neck area was the primary source of dermal exposure due to minimal protection. This study links PAH to cancer diagnosis however is was not explicitly proven as the causative agent. This study was completed at two fire and rescue stations on the southern coast of England. Subjects were randomly chosen, wipe samples were collected of skin and personal protective equipment (PPE) as well as the work environment. The storage methods of the firefighters' gear were observed during the study. The study found an increased concentration on hands, an increased amount of PAH found in masks. The study concluded that non-practice of the use of PPE and cleaning of the PPE can adversely affect the health of firefighters.

A study with collaboration between Ottawa Fire Service, The University of Ottawa, The University of Toronto, and Health Centers was conducted with four fire stations. Firefighters (N=28) were selected from stations based on call volume and were provided a sample collection “toolbox” with collecting gear and instruction manual. This study is based on a meta-analysis of 32 studies completed related to excess cancer risk for firefighters (LeMasters et al., 2006). Two groups of chemicals were studied, metal and polycyclic aromatic hydrocarbon (PAH). Urine analysis completed before and after on shift suppression, on average there was an increase in PAH metabolite levels. Sample collection of gear, storage with wiping PPE before and after fire events, samples were taken between January and October 2015. Found a significant amount of airborne PAH post suppression as well as dermal exposure. Companion studies and earlier studies (Fent et al., 2014; Britz-McKibbin et al., 2016; Keir et al., 2017) found a major route of PAH exposure through dermal exposure. Noted that stations that performed the cleaning of PPE and provided a second set of PPE lead to decreased exposure. The study recommend continuing to develop intervention strategies for site decontamination and protocols to minimize cross containment.

Cultural Change and Cancer Risk Reduction

A study conducted by Harrison, T. R., Yang, F., Anderson, D., Morgan, S. E., Muhamad, J. W., Talavera, E., … Kobetz, E. (2017), concluded that in the Palm Beach County Fire Department the “epidemic” of cancer had surpassed heart disease, data showed that there was a decrease in line of duty deaths from injuries since the 1970s with the exception to 9/11. A cancer diagnosis has increased with Boston reporting line of duty deaths related to cancer from 2002-2014 to have increased 67%. Fire and rescue companies have resilience in the face of danger however strong cultures can affect that resilience. Dirty bunker gear is a symbol of hard work and a cultural stigma is now being seen as a health risk. Dirty gear is known to lead to contact exposure of carcinogens and an increased risk of a cancer diagnosis. Historically 80% of firefighters saw dirty gear as a “badge of honor”, this study shows that down to 20%. Change is happening from the bottom-up and top-down, change is happening in training academies.

Cultural change is slower. “The Model of Change Processes for Risk Reduction and Resilience is presented as a framework for cultural change to reduce risk and increase resilience”. Testing of PPE and skin for learning the pathways of exposure was studied by Fent, K. W., Alexander, B., Roberts, J., Robertson, S., Toennis, C., Sammons, D., … Horn, G. (2017), they studied the contamination of PPE and the skin and what was the effectiveness of the decontamination process. They completed a study with 41 firefighters including 3 crews with 12 firefighters per fire suppression session. Performed wipe samples pre and post-fire suppression. Contamination of PPE and skin as well as field decontamination was limited by size. The study concluded that PPE, skin, neck, and hands were contaminated with PAH during fire suppression tasks, but noted the level was varied by what job assignment the firefighter performed. Contamination levels increased with each fire if not decontaminated after each fire. Wet soap was found to be the most effective for decontaminating. This study provided a greater understanding of exposure pathways and measures taken to reduce exposure.

Firefighter Cancer Registry

Enacted on July 7, 2018, President Trump signed the Firefighter Cancer Registry Act of 2018. This bill requires the Centers for Disease Control (CDC) to develop and maintain a voluntary registry for firefighters. Part of the information provided will include the age of diagnosis and years of service, it will use existing state data to assist with compiling the information. The bill “requires the CDC to develop a strategy to maximize participation, develop guidance for state agencies, encourage inclusion among participants, and to seek feedback from nonfederal experts. The CDC would also be required to ensure the data collected is made public and accessible for research” (“President Trump Signs,” 2018). The CDC registry’s goals will use” the registry to raise awareness about better ways to protect firefighters from known cancer risks, including advancements in the design and care of personal protective equipment and practices that can lower firefighters’ exposure to hazardous substances’ ( CDC, 2019). The ultimate goal is to make advancements in the design and care of PPE and invest and promote practices to lower firefighter's exposure to hazardous materials.

Methodology Subjects

The target population for this study is paid firefighters in Southern Nash County. The sample selected for the survey will include various positions within the department. This study will draw its samples from firefighters in the following departments: Bailey, Spring Hope, Stanhope, Middlesex, and Ferrells with email distribution to firefighters within the departments (N= approximately 165). This study will use a frequency distribution sampling technique. To achieve a maximum number of participants an email distribution list was chosen for the survey to be administered. Department Chiefs report that all firefighters at the selected stations have access to their department email and this was the best method to send out the survey. Instrument Survey software from Surveymonkey.com will be the instrument used to collect data to include but not limited to cleaning PPE, storage of PPE, exhaust systems, and use of cleaning wipes linking increased levels of PAH and exposure to cancer-causing agents.

The decision to use Surveymonkey.com for this research was due to the software’s ability to get responses in real-time, analyze data to reveal insights, and easily share presentation-ready charts and reports. The availability and ease of access is another reason to use Surveymonkey.com. Trying to reach firefighters at these various stations to complete a paper survey would be challenging, requiring a great amount of time on delivery and picking up surveys. Using a mailed-in survey would require extra costs. Surveymonkey.com allows for surveys to be administered via mobile, web services, and social media. The survey can be completed in their free time from their phone or computer. Surveymonkey.com uses hundreds of free, professionally designed survey templates built by expert survey methodologists (Surveymonkey, 2017). This accommodates the need for time with no cost involved. Some of the most commonly used survey question types are multiple-choice, rating scales, comment/easy box, and demographic questions (Surveymonkey, 2017). This research study will use a rating scale and demographic questions to analyze cleaning procedures for PPE and equipment that link the finding of cancer-causing agents and the need for further education/training on cleaning to prevent exposure to cancer-causing agents.

The rating scale questions will use a “Likert” scale to analyze and group data. Demographic questions gather information about the participant’s background while keeping participant information anonymous.

Procedure

An email will be sent to all members of the Southern Nash County fire departments. The email will provide a link with a message that states: “Your participation in this survey will help researchers attempt to evaluate cleaning procedures for PPE as well as storage of PPE and equipment to decrease the risk of exposure to cancer-causing agents.” The link will send the participates directly to the questionnaire in which they will begin to read and answer questions. The survey results will be sent to Surveymonkey and the data will then be analyzed. The individuals completing the survey will remain anonymous as the survey does not require names to be posted to complete the survey, after four weeks the survey will be closed and all the data will be collected. After the data collection and the data are analyzed an email will be sent to the chief of the fire departments included in the study. This will provide information to allow for increased training on proper cleaning and decontaminating of PPE and equipment. Information can also be used to write grants for industrial washers and other decontaminating equipment.

Summary

Studies have shown that firefighters are more likely to be diagnosed with cancer at an increased rate than the average person. Cancer in the fire service has become an epidemic. Over the last few years, a discussion of how to address the rise in cancer diagnosis in firefighters has become a hot topic. Larger departments are addressing the issue with providing a second set of PPE and conducting gross field decontamination. The process can be expensive and smaller departments especially local volunteer departments may not have the money to be able to afford to utilize those expensive techniques for decreasing the risk for exposure. Further education and training for these departments is vital to save lives and to decrease the diagnosis of cancer. This study will assist with volunteer fire departments to work towards improving education and training in the need for decontamination and cleaning of PPE and storage of PPE to prevent further exposure to cancer-causing carcinogens.

References

1. Britz-Mckibbin, P., Shaw, D., Gallea, M., Vandenenden, L., House, R., Verma, D. K., & Mccarry, B. E. (2016). Evaluation of Firefighter Exposure to Wood Smoke during Training Exercises at Burn Houses. Environmental Science & Technology, 50(3), 1536– 1543. DOI: 10.1021/acs.est.5b04752
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3. Fent, K. W., Alexander, B., Roberts, J., Robertson, S., Toennis, C., Sammons, D., … Horn, G. (2017). Contamination of firefighter personal protective equipment and skin and the effectiveness of decontamination procedures. Journal of Occupational & Environmental Hygiene, 14(10), 801–814. https://doi.org/10.1080/15459624.2017.1334904
4. Fent, K. W., Evans, D. E., Booher, D., Pleil, J. D., Stiegel, M. A., Horn, G. P., & Dalton, J. (2015). Volatile Organic Compounds Off-gassing from Firefighters’ Personal Protective Equipment Ensembles after Use. Journal of Occupational and Environmental Hygiene, 12(6), 404–414. DOI: 10.1080/15459624.2015.1025135
5. Firefighter Cancer Registry Enacted. (2018). Professional Safety, 63(8), 11. Retrieved fromhttp://search.ebscohost.com/login.aspx? direct=true&db=bth&AN=131049626&site=eds-live&scope=site
6. Harrison, T. R., Yang, F., Anderson, D., Morgan, S. E., Muhamad, J. W., Talavera, E., Kobetz, E. (2017). Resilience, culture change, and cancer risk reduction in a fire rescue organization: Clean gear as the new badge of honor. Journal of Contingencies and Crisis Management, 25(3), 171–181. DOI: 10.1111/1468-5973.12182
7. Keir, J. L., Akhtar, U. S., Matschke, D. M., White, P. A., Kirkham, T. L., Chan, H. M., & Blais, J. M. (2020). Polycyclic aromatic hydrocarbon (PAH) and metal contamination of air and surfaces exposed to combustion emissions during emergency fire suppression: Implications for firefighters exposures. Science of The Total Environment, 698, 134211. DOI: 10.1016/j.scitotenv.2019.134211
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9. President Trump Signs Spending Package That Includes $1 Million for Brown's Firefighter Cancer Registry Act: U.S. Senator for Ohio. (2018, September 28). Retrieved from https://www.brown.senate.gov/newsroom/press/release/president-trump-signs-spending- package-that-includes-1-million-for-browns-firefighter-cancer-registry-act.
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