1
Report of the Préventica International Symposium, June 21, 2017,
Paris, France
Chemical Risks: Health and Quality of Life among Firefighters:
Focus on Excess Cancer Risk
2
ABSTRACT
Background: Firefighting is a hazardous profession, with exposure to multiple toxicants
which can result in significant illnesses including cancer. Methods: To address this issue,
the Préventica Symposium for health and safety stakeholders was organized by the
French National Syndicate of Firefighters and Administrative Personnel for Prevention
(SNSPP-PATS), AFNOR, and Laboratoire Prevor on June 21, 2017 in Paris, France.
Participants from five countries discussed their knowledge of the chemical risks—
especially potential carcinogens—involved in fire smoke/soot exposure, presented
existing preventive measures and shared the impact and proposals for amelioration
methods. Results: Firefighters are exposed to potentially carcinogenic substances.
Published data from various countries clearly show evidence an increased incidence of
cancer and cancer deaths among firefighters. Some countries have already undertaken
measures to qualify these exposures and have established preventive measures.
Conclusion: This symposium provided a description of the international situation,
evaluation of steps for long-term prevention harmonization, and description of methods
for changing existing prevalent attitudes.
3
Key Words: Firefighters, Cancer; Firefighters, Carcinogens; Firefighters, Soot
Exposure; Firefighters, Fire Smoke Cutaneous Exposure; Firefighters, Fire Smoke
Dermal Exposure.
BACKGROUND
This paper is a report of the Préventica International Symposium on Chemical
Risks: Health and Quality of Life among Firefighters: Focus on Excess Cancer Risks,
Paris, France, June 21, 2017. It includes summarized data from PubMed and Google
literature searches using search terms “Firefighters and Cancer” and “Firefighters and
Carcinogens” together with some publications furnished by the FireSmoke Coalition,
Indianapolis, Indiana, U.S.A.
List of Symposium Presenters and Topics
Comparative Scientific Approach: Noxious Nature, Human and Environmental
Impact
Phillipe Sarron (France): Event Presentation
Lucien Bodson (Belgium): What are the chemical dangers? Which are
the principal large chemical classes and
their associated risks?
Richard Amnotte (Canada): Review of Experience
Jefferey Burgess (USA): Review of Experience
Blanca Cifuentes Valencia (Spain): Review of Experience
Pierre Garioud (France): Review of Experience
Strategy of the Efforts against the Different Effects on Health, Existing Solutions
Short- and Long-Term Solutions, Arousing the Interest of Stakeholders,
Development, Research
4
Sébastien Bouvier (France): Presentation of the Results of the Working Group
on Smoke Toxicity
Lucien Bodson (Belgium): Necessity for Coordination of all Stakeholders:
Development, Information, and Adapted Products
Christian Lembeye and
Paul Malassigné (France): Prospective: Initiation of Applied Research for
Interdisciplinary Development; Intensifying the
Public-Private Enterprises and Management of
Risks
5
INTRODUCTION
Occupational cancers are a significant worldwide problem. A conservative
estimate is that of all cancers occurring in Europe, eight percent are attributable to
workplace chemical substances exposures. This means that mortality from such cancers
exceeds that of deaths from workplace accidents. [1,2]
Toxicants released from incomplete combustion of flammable materials,
including carcinogens, may have a variety of adverse health effects among firefighters,
including cancer. [3] Published international research corroborates the increased risk of
cancer in this population. [4-35] In 2010, the International Agency for Research on
Cancer (IARC) determined that occupational exposure as a firefighter is possibly
carcinogenic to humans (IARC Group 2B).
There is a great deal of variability in approaches to exposure reduction across the
fire service internationally. Some brigades have established protocols for limiting
inhalational and dermal fire smoke exposures at the fire scene. International collaboration
is needed to determine which approaches are the most effective, and then to disseminate
these best practices. The goal of the Préventica Symposium reported here was to improve
the understanding and reduction of cancer risks among firefighters by evaluating current
fire service practices in a sampling of the countries Belgium, Canada, France, Spain,
United States.
There are more than 133 million primary organic and inorganic substances
registered with the Chemical Abstract Service (CAS) [36] as well as more than 10 million
dangerous chemical mixtures. Approximately 150,000 are commercialized products, and
there are more than 30,000 known toxic substances. However, the focus of this
6
symposium report will be on those chemical substances found in fire smoke and soot and
which have the potential to be carcinogenic to firefighters exposed primarily by the
dermal route.
Certain chemical agents can induce DNA adducts [37] such as aldehydes
including acrolein, which is present in fire smoke. [38] Fire smoke can also contain
polycyclic aromatic hydrocarbons (PAHs), which can induce these effects. [39] There are
more than 1,500 PAHs; Beno[a]pyrene is usually considered the reference compound for
this group of chemicals.
Firefighters encounter toxicological risks in four settings: 1) during firefighting;
2) during hazardous materials (HAZMAT) responses; 3) in fire stations; and 4) in their
private lives. Although they may encounter toxicants by all four exposure routes—
inhalation, dermal, ocular, and ingestion—this symposium report concentrates on the
dermal exposure route to chemical substances known or suspected to be human
carcinogens.
Fire smoke composition varies widely from fire to fire, depending on the type,
burning or smoldering materials, temperatures reached, and so on. There are a great many
degradation products that are present in fire smoke; these can be irritants, corrosives, and
toxicants. This symposium report focuses on those which are potentially carcinogenic and
explains how workers can protect themselves with protective measures or preventive
measures such as decontamination.
The International Agency for Research on Cancer (IARC) classifies chemicals
and chemical groups according to the following scheme (Table 1). [38]
7
Table 1. IARC Classifications
IARC Group Classification Explanation
Group 1 Carcinogenic to Humans
Group 2A Probably Carcinogenic to Humans
Group 2B Possibly Carcinogenic to Humans
Group 3 Not Classifiable as to its Carcinogenicity to Humans
Group 4 Probably not Carcinogenic to Humans
Table 2 lists some known and potential carcinogens to which firefighters may be
exposed in the performance of their duties and IARC Classifications.
Table 2. Potential Firefighter Exposures and their IARC Classifications
Group 1 Group 2A Group 2B
Soot Creosotes Acrylonitrile
Benzo[a]pyrene (PAH) Ethylbenzene 11 Different PAHs
Benzene Cyclopenta[c,d]pyrene
(PAH)
Naphthalene
(Volatile PAH)
Particulates Dibenzo[a,h]anthracene
(PAH)
Furans
Formaldehyde Dibenzo[a,i]pyrene
(PAH)
Hexachlorobenzene
Diesel Exhaust Wood Dust Silica (Fibers)
Dioxins Lead Styrene
Arsenic Teflon (PTFE) Acetaldehyde
Asbestos Tetrachloroethylene Toluene Diisocyanate
(TDI)
Silica (Dust) Ethylcarbamate
(Urethane)
Methylmercury and its
Organic Salts
Cadmium Dichloromethane
(Methylene Chloride)
Cobalt
1,3-Butadiene
Ethylene Oxide
Vinyl Chloride
Trichloroethylene
(TCE)
8
Soot is a residue of incomplete combustion and can absorb and carry re-
arrangement molecules of PAHs and other volatile carcinogenic organic compounds. It
adheres to or can penetrate around firefighters’ personal protective equipment (PPE),
resulting in skin contamination, particularly of the hands, face, and neck. [40]
Nanoparticles, with a size of less than one micron, are present in large quantities in fire
smoke, but there is currently little available data on their potential health effects. [41]
MATERIALS AND METHODS
A pilot study group was developed from a database project of the health and
quality of life section of the French Fire Service (Service du Sapeurs-Pompiers, SQVS).
An international symposium for health and safety stakeholders was then organized by the
French National Syndicate of Firefighters and Administrative Personnel (SNSPP-PATS),
ANFOR, and Laboratoire Prevor on June 21, 2017 in Paris. Speakers from each
participating country were requested to relate their own knowledge of the chemical risks
involved in fire smoke exposure, to describe existing preventive measures and their
impact, and to present proposals for further amelioration methods.
Also included are summarized data from PubMed and Google literature searches
using search terms “Firefighters and Cancer” and “Firefighters and Carcinogens” together
with some publications furnished by the FireSmoke Coalition, Indianapolis, Indiana,
U.S.A.
RESULTS
9
Following are summaries of the presentations made at the Symposium by
representatives from the various participating countries.
Belgium. Presentations by the Belgian representative dealt with the extensive
range of potential chemical exposures which firefighters may encounter in the
performance of their duties. This information has been incorporated into the Introduction
and Discussion sections and is not repeated here for brevity.
Canada. According to international studies, cancerous pathologies constitute the
most severe menace to the health of firefighters. [42] In Ontario, Canada, the median age
at death of professional firefighters was 64 years, as compared to 80.8 years for men and
84.5 years for women in the general Canadian population. In Canada, certain types of
cancers are considered to be occupational illnesses. This is notably the case in Quebec
Province which acknowledges the occupational illness nature of several types of cancer.
In some other Canadian Provinces, the number of acknowledged occupational cancers is
increased to 15 types.
In North America, the following types of cancer have been described among
firefighters (Table 3):
Table 3. Firefighter Cancers and Prevalence.
Relative Risk
Among Firefighters
Cancer Type
2.02 Testicular
1.53 Multiple Myeloma
1.51 Non-Hodgkins Lymphoma
1.39 Skin
1.31 Brain
1.31 Malignant Melanoma
1.28 Prostate
1.21 Colon
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In the province of Quebec, Canada, the increased prevalence among firefighters
of the following cancers has been acknowledged as being of occupational origin (Table
4). [43]
Table 4. Recognition in Quebec Province, Canada of Certain Cancers Among
Firefighters.
(Adapted from data of the CNESST [43], Articles 9.11 and 9.11.1)
Cancer Type Conditions
Kidney 20 years
Bladder 20 years
Larynx 15 years for smokers; 10 years for nonsmokers
Lung 15 years for smokers; 10 years for nonsmokers
Mesothelioma No minimal exposure duration
Multiple Myeloma 15 years
Non-Hodgkins Lymphoma 20 years
Canadian Existing Measures for Individual Personal Protection and Prevention
During fire interventions, wearing self-contained breathing apparatus (SCBA) has
been done systematically for years during the attack phase (fire suppression/knock-
down), in hazardous materials responses, and for Chemical, Biological, Radiological,
Nuclear, and Explosives (CBRNE) intervention. In contrast to the phase of fire
suppression, during the phase which consists of ensuring that residual cinders cannot
cause reignition (“overhaul”) when less strenuous activities are undertaken and the need
to change or recharge SCBA air tanks has often resulted in SCBA not being worn during
overhaul.
In this manner, certain chemical exposure risks have not been thoroughly
evaluated or completely underestimated, such as the following:
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• Effects of gases escaping from hydraulic equipment.
• Benzene exposure from operating vehicles in the equipment bays of fire stations:
more than five years, this can correspond to 450 months of benzene exposure
more than 37.5 years for French quarry workers. Even if the level of benzene is
lower in the fuel used in fire apparatus, it must also not be forgotten that diesel
exhaust fumes are also carcinogenic and are produced by operating fire apparatus
in equipment bays.
Looking to the Future
Because toxicological knowledge necessarily post-dates research into new
chemical substances and sometimes their commercialization and use in industry, it is
necessary to be aware of developing trends and possible effects of, for example,
nanomaterials from accidental exposure or dismantling operations [44].
There are three types of hazards: the known and more or less taken into account
according to the state of the art (i.e., fire, explosion risk); the neglected (i.e., overhaul
operations, benzene, CO/CO2/CN-); the unknown (which means non-quantifiable at
present because not identified or simply suspected).
Preventive measures, personal protective equipment, and complementary hygiene
must also be considered. In Quebec Province, Canada, the CNESST (Commission des
Normes, de l’Equité, de la Sante et de la Sécurité du Travail) has developed a best
practices guide [45].
France. Pourny [3] edited a report on the dangers of the activities of firefighters
which is a classic reference work on matters of firefighter safety. It details several
accidents and contains proposals for improved protection against the inherent risks of
firefighting and for decreasing the number of victims of line-of-duty accidents.
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The French 2004 “Modernization of Civil Safety” law acknowledges the
dangerous character of firefighter activities. Creation of the CHST became obligatory in
all firefighter departmental groups, both professional and volunteer. An office for
accident prevention-investigation (BPAE) was created by De Lavernée, Director of
Defense and Civil Safety, on March 15, 2005.
Such efforts contributed to a decrease in fire service-related deaths and
occupational accidents at a time when the number of interventions continued to increase.
Supplemental benefits on operational difficulties were agreed to by professional
firefighters in the staging report of May 2004, and others covered volunteer firefighters in
the law of July 21, 2011.
While reduction of immediate and accidental risks to firefighters were tangible
results of Pourny’s review [3] and the 2004 “Modernization of Civil Safety” law, it is
now time to evaluate delayed risks such as development of and mortality from cancer
over 20 or more years.
Such delayed risks are generally due to exposure to toxicants, especially by the
inhalation and dermal routes. International epidemiological studies have revealed
excesses of development of and mortality from cancer most likely due to exposure to a
wide variety of known and suspected carcinogens in fire smoke amongst firefighters
responding to urban structural fires, wildfires, industrial fires, etc. [39,45]. In addition,
there are issues with inadequate protection from dermal exposure from contaminated or
impregnated firefighter turn-out gear, with fire smoke and soot being able to penetrate
especially onto the least protected body areas [40]. This has lead to individual and group
13
preventive actions during and after interventions, and has prompted recommendations for
medium- and long-term medical follow-up [46,47].
There remains the difficulty of promulgating laws to address these issues in
France because the specific model for Civil Safety does not rationally permit making
such laws on the same basis as observed internationally. Because of concerns about the
direct and indirect costs of such occupational illnesses among firefighters as well as the
significant impact on firefighters themselves and their families, it is important to pursue
promulgation of such laws in France. A recent report of the CNRACL (Caisse Nationale
des Retraites des Agents des Collectivités Locales) (National Pension Fund of Local
Government Agents) [48] contains an analysis of these issues and presents the
international state of the art and an action plan for best practices.
Spain. In the autonomous region of Madrid, Spain, firefighters are involved in
managing nuclear, biological, and chemical incidents. Between 2013 and 2016, there
were 19 interventions in industrial facilities or fires caused by chemical substances and
53 other interventions for chemical spills involving various substances including
hydrocarbons and hydrochloric or sulfuric acids.
The 40,500 Spanish firefighters assigned to more than 1,000 fire stations have an
applicable regulation (Figure 1). Spanish scientists are evaluating contamination with
carcinogenic particulates and the effects of fire smoke. A correlation appears to exist
between firefighting and development of cancers of the prostate and testicles.
14
Figure 1. Current Occupational Safety and Health Legislation in Spain.
There is generally a long latent period between initial exposure and the
appearance of cancerous pathology, which may be as many as 30 years or more (i.e.,
pleural mesothelioma following prolonged asbestos exposure). As a consequence, the
majority of firefighters’ occupational cancers are contracted during multiple workplace
exposures and may not be diagnosed until after retirement. The best methods of action
remain those of prevention and early detection.
A Spanish working group for firefighters and cancer was created in 2016 to
evaluate means for amelioration and reduction of cancer risk in this population. Training
15
is a mainstay of the proposed program with some periodic refresher courses on PPE and
management of nuclear, biological, and chemical incidents (Figures 2-4).
Figures 2-4. Spanish Periodic Refresher Training Courses.
Each fire station has been provided with a document, “Basic Safety Behaviors at
Work,” relative to exposure to carcinogenic substances. A medical surveillance program
has also been instituted consisting of the following:
• An annual medical examination.
• Routine screening blood tests.
• PSA (Prostate Specific Antigen) (for male firefighters > 45 years of age).
• Serology for hepatitis A and B.
• Audiometry.
• Visual acuity testing.
• Spirometry.
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• Echocardiography (for firefighters 50 years old and older, or who have an
increased cardiac risk).
• Physical testing (Figure 5).
Figure 5. Firefighter Physical Testing
United States. In the United States, recent epidemiological studies pertaining to
an increased risk of cancer among American firefighters have been published. [4,5,9] A
retrospective study among 29,993 firefighters from Philadelphia, Chicago, and San
Francisco (1950-2009) found that firefighters have a nine percent greater risk of a cancer
diagnosis and a 14 percent greater chance of mortality from cancer than those in the
general population [4,5]. Specifically, there was an increased risk of cancers of the lungs
(10 percent), gastrointestinal tract (26 percent), and kidneys (29 percent), as well as
mesothelioma (100 percent). [4,5] An increased incidence of cancer among California
17
firefighters (3,996 cases from 1998-2007) was also noted for the following cancers:
malignant melanoma (80 percent); multiple myeloma (40 percent); acute myeloid
leukemia (40 percent), esophagus (60 percent); prostate (50 percent); brain (50 percent);
kidney (30 percent). [9]
According to the International Association of Firefighters (IAFF), 61 percent of
the causes of occupational-related deaths among firefighters were due to cancer between
2002-2016. The Firefighter Cancer Support Network has compiled pertinent data from
multiple studies to establish levels of prevalence of cancers among firefighters (Table 5).
[49]
Table 5.
Cancer Type Increased Risk
(As Compared to the USA General Population)
Testicular Cancer 2.02 Times Greater Risk
Multiple Myeloma 1.53 Times Greater Risk
Non-Hodgkin’s
Lymphoma
1.51 Times Greater Risk
Skin Cancer 1.39 Times Greater Risk
Prostate Cancer 1.28 Times Greater Risk
Malignant Melanoma 1.31 Times Greater Risk
Brain Cancer 1.31 Times Greater Risk
Colon Cancer 1.21 Times Greater Risk
Leukemia 1.14 Times Greater Risk
Breast Cancer
(Females)
Preliminary Study Results from the San Francisco, CA Fire
Department
18
In partnership with the Tucson (Arizona, USA) Fire Service, a research study
funded by the U.S. Federal Emergency Management Agency (FEMA) was performed in
which samples of blood and urine were collected from firefighters before and after fire
responses and analyzed for chemical contaminants and cellular alterations. Instruments
were also furnished to firefighters for measuring airborne levels of dangerous chemicals
(Figure 6). The firefighters themselves could use these data to modify intervention
procedures to reduce their exposures.
Figure 6. Exposure Surveillance.
Exposure Surveillance
• Perform studies before and
after fires
• Surveillance of exposures by
the firefighters themselves
o Particulates
o Diesel exhaust
particulates
o Formaldehyde
o Organic volatile
chemical compounds
19
Firefighter’s turn out gear with SCBA offers excellent protection against inhaled
airborne chemicals, but does not prevent deposition of fire smoke soot particulates on
certain areas of the body. This study also addressed means of reducing cutaneous
exposures to firefighters (Figure 7).
Figure 7. Transcutaneous Exposure.
Preliminary measurements of PAHs (Polycyclic Aromatic Hydrocarbons)
metabolites in firefighters revealed that exposure is increased in both firefighters who
enter burning buildings and among fire apparatus drivers (Figure 8).
20
Figure 8. Concentration in urine of metabolites of polycyclic aromatic
hydrocarbons (PAHs).
Biomarkers can provide information about the short- and long-term toxicity
potential of firefighting. Some of these tests are summarized in Figure 9. In addition, the
first evaluation of differences in microRNA (miRNA) expression comparing incumbent
firefighters with new recruits, adjusting for age and other potential confounders, has
demonstrated a decrease in circulating miRNAs which have tumor suppressing effects
and an increase in two circulating miRNAs which have oncogenic effects [50], providing
a potential mechanism to help explain increased cancer risk among firefighters.
In addition, the first year of a research study (the Fire Fighter Cancer Cohort
Study (FFCCS) to elaborate, develop, and test a multi-center prospective cohort over the
long-term focused on fire smoke soot exposures and their carcinogenic effects and
ultimately on the prevention of cancer among firefighters in the US has been initiated in
21
the states of Arizona, Florida, and Massachusetts, also funded by FEMA (Federal
Emergency Management Agency).
Figure 9. Biomarkers of Carcinogenic Effects.
Short-term effects:
• In vitro bioassays: testing extracts of free
urine as an indicator of exposure to
biologically active compounds
o Test with the arylhydrocarbon
receptor (AhR)
▪ Response to PAHs, dioxins,
furans, etc.
o Can cause DNA lesions
▪ Through the “p53” pathway
Long-term effects:
• Epigenetic changes
o Micro-RNA and gene methylation
Acute Ocular or Cutaneous Exposure to Irritants and Corrosives
Currently, there are some measures to protect workers including firefighters with
direct chemical substances exposures that limit their effects: wear PPE, and, in Europe or
countries such as Canada, Australia, Mexico, South Africa, Brazil, India, or China, use
active decontamination solutions in case of splashes. Self-decontamination and removal
of contaminated clothes, if possible, can help to limit contact with aggressive chemical
agents. It is necessary to remove the maximum amount of irritant or corrosive substances
22
from the surfaces of the skin or eyes by mechanical action, to limit their tissue diffusion
by using osmotic pressure to create a flux from the inside to the outside of exposed
tissues, and to reduce their irritant or corrosive potential by trapping them if possible. It is
thus ideal to rinse with a hypertonic, amphoteric, chelating agent such as Diphoterine®
solution (Laboratoire Prevor, Valmondois, France) [51] which retains water properties
and offers limitation of diffusion of aggressive chemicals based on osmotic pressure and
mitigation of their irritant/corrosive potential. When this is not available, wash with
water.
Diphoterine® solution acts equally well on acids and bases [51] and restores the
physiological tolerable pH of the skin or eyes [52,53]. It stops diffusion of the chemical
agent by physically creating a flux from the tissue interior to the exterior. Diphoterine®
solution is nontoxic, not irritating, not sensitizing, and not mutagenic [54]. No adverse
effects have been reported to the manufacturer’s materiovigilance system. In stopping the
aggressive tissue effects of the chemical agent, it also decreases or stops the pain [55,56],
although it is devoid of analgesic properties.
Diphoterine® solution’s efficacy depends on the delay to intervention – the longer
the intervention is delayed, the more the chemical lesions have developed—but it
presents an interest at each level of patient management (industrial site,
ambulance/firefighter intervention, hospital) for ocular and cutaneous irritant and
corrosive chemical exposures. [57,58] Diphoterine® solution also acts on incapacitating
and lacrymating agents. [59,60]
Diphoterine® solution stops the chemical injury evolution and can ideally be used
within the first minute after the chemical splash, limiting the lesion to either no injury or
23
minor injury and stops the pain. When used by rescuers within the first 30 minutes, it
decreases the pain and limits the lesions to being superficial. When used at the hospital
from 1-24 hours after chemical contact, injury treatment and grafting can be done under
good conditions [61].
Procedure for Emergent Decontamination with Diphoterine® Solution (Figure 10)
1. Protect yourself with proper PPE including impervious gloves and safety glasses,
safety goggles, or an SCBA face mask.
2. Remove the victim’s contaminated clothing.
3. Spray Diphoterine® solution on exposed body surfaces including those that may
be injured or bleeding. Diphoterine® may still be efficacious even after several
hours of chemical agent contact. Use 200 mL of Diphoterine® spray for a 9%
TBSA (Total Body Surface Area) exposure or an eyewash of 50 mL within the
ten following seconds or an eyewash of 500 mL within the first minute following
the exposure.
4. Request medical evaluation and advice.
Figure 10. Diphoterine® Solution Decontamination.
24
For mass causality chemical decontaminations, it is necessary to provide first aid
to large numbers of persons in a limited time and with a minimum of run-off effluents.
Distribution of personal decontamination kits (Figure 11) could be a solution, avoiding
the need to assemble victims outside the safety perimeter so that they do not converge
toward hospitals and potentially secondarily contaminate health care workers.
Figure 11. Personal Decontamination Kit.
DISCUSSION
An international system, the CAREX database [62], allows estimating and
suspecting the number of workers exposed to carcinogens by country, carcinogenic
substance, and industry types among States Members of the European Union. There are
32 million workers in Europe (Table 6). Amongst the 15 preponderant potentially
carcinogenic chemical substances are diesel exhaust fumes, chromium IV salts, wood
dust, benzene, formaldehyde, asbestos, and tobacco.
25
Table 6. Number of Workers Exposed to Carcinogenic Risks by Country between
1990-1993—CAREX database.
Country Number of Workers x 1,000 % of Exposed Persons
Austria 790 25
Germany 8,300 24
Belgium 730 21
Denmark 680 24
Spain 3,100 25
Finland 510 24
France 4,900 23
Greece 910 27
Holland 1,100 17
Ireland 260 24
Italy 4,200 24
Luxembourg 48 25
Portugal 970
24
United Kingdom 5,000 22
Sweden 820 23
European Union 32,219 23
Table 7 displays existing data concerning new cancers versus occupational
cancers, as well as those cancers known to be occupational illnesses for the period 1999-
2000 [63,64].
26
Table 7. CAREX Data.
Country Population
(Millions)
New
Cancers/
Year
Occupational
Cancers
Cancers Known
as Occupational
Illnesses
Spain 41.8 161,748 6,470 –
13,587
14 0.10-022%
France 57.3 250,000 10,000 900 9.0%
United
Kingdom
57.5 241,875 9,670 806 8.3%
Germany 79.1 367,641 14,700 1,889 12.9%
Belgium 10.2 46,339 1,850 149 8.1%
Denmark 5.1 29,657 1,180 79 6.7%
Finland 5.2 22,201 890 110 12.4%
Scientific research has been undertaken by the French Ministry of Health to
correlate international data with national data. As has been observed in Belgium and
Holland, certain preventive measures can limit the number of new cancer cases.
There is a prevalent misconception that the more a firefighter is covered with
traces of exposure to fumes and soot, the more he is considered to be courageous and
experienced. This image should be actively discouraged. Instead, a program of limiting
firefighter exposure to chemical risks should be developed, substituted, and actively
promoted.
Research needs to be performed to do the following:
• Better understand the phenomena to the greatest extent possible; to understand
which contaminants are involved;
• Establish individual and group preventive measures;
• And finally, as this may prove to be efficacious, adopt personal and equipment
decontamination measures.
Research and innovation for chronic exposures:
27
The working environment of firefighters is propitious for repeated exposures to
carcinogenic and toxic chemical substances. Certain working methods have already
allowed reducing such repeated exposures to contaminants. A workplace health culture
must be evolved for firefighters, as has been done in other professions where chemical
substances exposures may occur. Future research should be pursued for identifying
efficacious solutions for prevention and protection from these chemical exposures.
Training is an important part of preventive measures. The Pubic Association in
Health and Workplace Safety – Section of Municipal Affairs in collaboration with the
Association of Fire Chiefs in Quebec, Canada and the principal firefighters’ unions have
produced a series of video presentations as training aids on cancer prevention amongst
firefighters [65].
Conclusions
Some common themes emerge from the June 2017 Préventica Symposium and
literature review:
• Firefighters are exposed to extremely complex mixtures of potentially toxic and
carcinogenic chemical substances, and these vary widely from fire-to-fire or with
HAZMAT or other similar responses.
• The focus of the Préventiva Symposium was mainly on the potential carcinogenic
risks for firefighters as opposed to all possible chemical exposures.
• Literature reviews are consistent in that firefighting is associated with an
increased risk of developing or mortality from various cancers. While studies are
somewhat inconsistent in which cancers are increased, the “weight-of-the-
evidence” is clear.
• While wearing of properly fitted and maintained SCBA should protect against
most inhaled toxic substances, not wearing such respiratory protection during
overhaul operations can result in potential increased cancer risk and must be
addressed, either by departmental actions or regulations/guidelines.
• Potential skin exposures are not completely protected against by currently used
firefighter turn-out gear. Areas of the body where the skin is more highly vascular
and relatively thinner may present the most risk for absorption of potential
28
carcinogenic substances by the dermal route. Head, face, neck, hands/wrists do
not seem to currently be adequately protected by utilized cowls and gloves worn
without under-gloves.
• Contamination from fire smoke soot can be transmitted to the Fire Station by
inappropriately decontaminated turn-out gear and equipment. Such equipment
should not be stored/carried in privately owned vehicles or in the crew
compartments of fire apparatus.
• Provision must be made for proper decontamination, washing, storage, inspection,
and removal from service of turn-out gear as needed.
• Firefighters must be encouraged, at the least, to utilize on-scene decontamination
measures and to have a thorough shower with water or an appropriate alternative
flushing fluid to remove fire smoke soot from themselves on return to the Fire
Station.
• Diesel exhaust from fire apparatus is also a potential concern, and proper venting
arrangements must be made for operating diesel equipment in Fire Station
equipment bays.
As Woody Allen said, “It is important to question the future, because we are
condemned to spend the rest of our lives there.”
“If you want to build a ship, don’t drum up people together to collect wood and
don’t assign them tasks and work, but rather teach them to long for the endless
immensity of the sea.”
-- Antoine de Saint-Exupery, 1948
29
LIST OF ABBREVIATIONS
AFNOR: Agence Française de Normalisation (French National Standard and
Certification Agency)
CHSCT: Comité d'Hygiène, de Sécurité et des Conditions de Travail (Committee of
Hygiene, Safety and Conditions at Work)
CMR: Cancérogène Mutagène Reprotoxique (Carcinogen Mutagen Reprotoxicant)
PPE: Personal Protective Equipment
SDIS: Service Départemental d’Incendie et de Secours (Department of Fire and Rescue
Service)
SNSPP-PATS: Syndicat National des Sapeurs-Pompiers Professionnels et Personnels
Administratifs, Techniques et Spécialisés (National Union of Professional Fiefighters and
Administrative Technical and Specialized Staff)
SQVT-SQVS: Santé et Qualité de Vie au Travail (Health and Quality of Life at Work) –
Santé et Qualité de Vie en Service (Health and Quality of Life in Service)
30
DECLARATIONS
Ethics Approval: Not Applicable
Consent for Publication: Not Applicable
Availability of Data and Material: Not Applicable
Competing Interests/Funding: Laurence Mathieu is an employee of Laboratoire
Prevor, manufacturer of Diphoterine® solution which is discussed in this article. Alan H.
Hall is a paid consultant to Laboratoire Prevor. Travel and attendance costs for the 2017
Préventica Symposium were paid by Laboratoire Prevor for the other co-authors, and
they report no other conflicts of interest.
Author’s Contributions: All authors except Alan H. Hall participated in and made
presentations at the Préventica 2017 Symposium. Laurence Mathieu wrote the first
manuscript draft in French. Alan H. Hall translated the manuscript into English,
performed literature searches, wrote additional sections, and edited and formatted the
manuscript for journal submission.
Acknowledgements:
Laboratoire Prevor (Prevor Laboratory) sponsored the 2017 Préventica symposium which
was consistent with its motto, “Anticipate and Save”.
Authors’ Information: Refer to Title Page
31
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41
Appendix 1
Suggested Protocol for Dermal Contamination Reduction
• Avoid transportation of individual PPE, tools, or contaminated equipment in the
crew cab of response vehicles or in privately owned vehicles.
• Perform a routine cleaning as rapidly as possible after the conclusion of an
intervention
• Wash if possible, or at least rinse contaminated PPE, tools, and equipment sooner
than on return to the fire station (reduction of contaminants transfer)
• Establish procedures to limit contamination:
o Transport materials, equipment, or PPE in hermetically-sealed bags and
place it all in a compartment
o Utilize impermeable coverings for seats
• Make a practice of assessing hygiene during interventions
• Remove the PPE cowl rapidly
• Wear disposable gloves to manipulate tools
• Remove PPE as soon as possible
In response vehicles, the following measures are recommended:
• Place contaminated PPE in an hermetically-sealed bag and place it all in a
compartment
• Turn down an impermeable cover if it is impossible to remove PPE (in winter,
for example)
• Anticipate decontamination of the crew section of the vehicle on return to the
garage if the utilization of sealed bags and covers is not hindered
The different steps of cleaning are:
• Light cleaning of the components of PPE exposed to contaminants, when out of
service
o Goal: to render the PPE sufficiently proper to be reused by the firefighter
o Means: to perform, as far as possible, on the fire ground before leaving to
eliminate and limit contamination of the crew areas of the vehicle and the
garage
o General rules:
1. Remove all residues by brushing
2. Eliminate substantial residues by rinsing with water
3. If necessary wash the stains with water and a detergent
a. Carefully utilizing a soft bristle brush
b. Or by hand in a service sink, dedicated to cleaning and
decontamination of PPE
42
For advanced cleaning, the instructions are as follows:
• Machine washing done in-house or by an external contractor, by competent
personnel
o Goal: annual decontamination or when routine cleaning is not sufficient
to remove stains such as oil or biological fluids
o Means: Utilization of an industrial extraction washing machine of which
the rotation speed is calibrated and using recommended detergents. Drying
should be done in ambient air, preferably by forced ventilation
In the areas of specialized cleaning, proceed in the following manner:
• Routine inspection
o Performed by the firefighter
o Physical damage
o Thermal damage
o State of being dirty and contamination
o Loss of reflectivity
• Advanced inspection
o Performed by senior personnel
o Complete physical inspection
o Inspection of the thermal barrier
o Inspection of the anti-moisture barrier
o After the 3rd year of the service life of the PPE and every year thereafter
A registry of maintenance inspections and repairs is to be kept daily and
comprises the major data as well as to insure its traceability:
• User name
• Manufacturer name and model
• Manufacturer’s identification number, lot number, or serial number
• Month and year of manufacture
• Date and comments for each advanced inspection
• Reason for advanced inspection or decontamination and performed by whom
• Date of removal from service
• Date and method of destruction
43
The storage area should be:
• Space dedicated to storage, external to ambient breathing air.
• Suspended on strong hangers
• Clean space, dry and well-ventilated
• Sheltered from light, ultraviolet and sunlight
• In a transport bag
• Assure that the PPE is clean (decontaminated}
• Dry PPE
• Utilization of hermetically-sealed bags as much as possible
• Avoid storage in personal vehicles
Measures for removal from service or destruction of equipment and materials are
the following:
• According to the manufacturer’s instructions and the NFPA 1851 guideline
• Program for verification and replacement
o In case of failure of verification:
▪ Could be used for training or in interventions which do not
include fire extinguishing or where mechanical protection is
required
▪ Distinctive labeling of non-certified PPE
▪ Destruction in a manner such that the PPE can no longer be
used.
44
Appendix 2
Proposed French Action Plan
As in Spain, the United States, and Canada, to have:
• An appropriate and harmonized system for measuring and recording exposures;
• Increasing the level of consciousness among personnel exposed to chemical
products and the danger of potential risks;
• Adding biomonitoring during and after exposures;
• Improvement of preventive actions.
In France, the considerations should take the following orientation:
The international group participating in the Préventica Symposium has provided a
useful model. Such cooperation is a pledge of prospective steps and of anticipation for
progress. Stating the principles of individual and group responsibility does not allow us to
act as if we know nothing. Stakeholders learn to do otherwise and adapt research in a
reactive and dynamic fashion. What also should be done is to also respect the principle of
public action and to respect the stakeholders in their functions and responsibilities. The
project should be guided, co-developed, clear and transparent so that action occurs in real
time. Training will continue to play a fundamental role.
Governance initially should be open to being interdisciplinary, a single
transparent remedy for action when faced with complexity and uncertainty. It should
cultivate and work on the interfaces (enterprise-public service; international).
The groundwork of the CHSCT should be adopted for proceeding to take action.
Epidemiological research should be brought to bear on the subject.
These steps should be transparent and voluntary in affirming that this CMR
theme is predominant and acts in consequence (voluntary engagement more than political
caprices) of which clear signs can be:
• Promoting the international network (French, Spanish, English speaking);
45
• Including firefighters in registries of cancer, ergo-toxicology…;
• Anticipating, accompanying, ameliorating by means of ad hoc (unannounced)
inspections.
It should be easy to be sensitive to recommendations for improvement of health
and quality of life in the fire service, which can be simple, not very expensive, and
efficacious.
46
REFERENCES
Malassigné P1, Amnotte R2, Lembeye C3, Bodson L4, Cifuentes B5, Garioud P6,
Mathieu L7, Morincome D8, Fortin Jean-Luc9, Burgess J10, Hall AH11
1Head of Logistics Technology Group and Heritage, Indre SDIS, Head staff management;
Member of the Personal Protective Equipment Commission (EPI S76A), AFNOR,
France, email: [email protected]
2Operations Assistant Director, Fire Safety, Levis City, Polytechnique School, Montreal;
National School of Public Health of Quebec, Quebec, Canada, email:
3Médecin du travail, évaluateur SQVT, AFNOR, France, e-mail: [email protected]
4Anesthesiologist Resuscitator, Emergency Department/SMUR, Emergency Response
Plans, University Hospital Center, Liege, Belgium, email: [email protected]
5Occupational Doctor, Fire Department, Autonomous Region of Madrid, Spain, email:
6Doctor in Civil Engineering, Lt. Colonel of firefighters, Responsible for Civil Protection
at the Interministerial Staff, Region of Lyon, France, email: [email protected]
7Doctor-Engineer in Chemistry ECM, Director of Scientific Affairs, Laboratoire
PREVOR, France. Moulin de Verville, 95760 Valmondois, France, email:
8 Health executive, head nurse health service and medical emergency firefighters, Landes
SDIS, France, email: [email protected]
9Occupational Doctor and Toxicologist, Department of Preventive Medicine, Saint-
Etienne; Poison Center and Toxicovigilance, Lyon, France, email: fortin.jean-
10Associate Dean for Research and Professor, Mel and Enid Zuckerman College of Public
Health, University of Arizona, Tucson, AZ, USA, email: [email protected]
11Medical Toxicologist, Toxicology Consulting and Medical Translating Services, Azle
and Springtown, Texas and Clinical Assistant Professor, Colorado School of Public
Health, University of Colorado-Denver, Denver, Colorado, USA, email:
47
ADDRESS FOR CORRESPONDENCE
Alan H. Hall, M.D.
Medical Toxicologist
Toxicology Consulting and Medical Translating Services
P.O. Box 1255
Azle, TX 76098
USA
Mobile phone: (817) 919-3208
E-mail: [email protected]
I no longer support FAX.