AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 52:261–269 (2009)

Prevalence and Risk of Asthma SymptomsAmong Firefighters in Sao Paulo, Brazil:

A Population-Based Study

Marcos Ribeiro, MD,1� Ubiratan de Paula Santos, MD,1

Marco Antonio Bussacos,2 and Mario Terra-Filho, MD1

The firefighters are at increased risk of respiratory disease as a result of exposure to smokeand dust. The aim of this study was to determine the prevalence and risk associated withrespiratory symptoms among city firefighters in Sao Paulo, Brazil.Methods A cross-sectional study utilizing the European Community Respiratory HealthSurvey (ECRHS) questionnaire was administered to firefighters and police officers, inorder to evaluate their respiratory symptoms.Results Complete respiratory data were obtained from 1,235 firefighters and 1,839 policeofficers. Among the firefighters, there were 55.5% never-smokers, 22.4% current smokersand 18.2% former smokers (P< 0.05). Among the police officers, there were 63.4%,18.6%, and 9.6% who were never-smokers, current smokers and former smokers(P< 0.05), respectively. Compared to police, firefighters experienced an increase inwheezing [OR¼ 1.63 (95% CI: 1.43–1.87)], wheezing with breathlessness [OR¼ 1.34(95% CI: 1.10–1.64)], wheezing without a cold [OR¼ 1.60 (95% CI: 1.32–1.95)], wakingwith tightness in the chest [OR¼ 1.20 (95% CI: 1.02–1.42)], and rhinitis [OR¼ 1.12(95% CI: 1.03–1.22)]. The prevalence of adult-onset asthma in never-smokers was9.3% and 6.7% for firefighters and police officers [OR¼ 1.23 (95% CI: 1.01–1.56)]. Anindependent association was observed between years employed, smoking, history ofrhinitis, and work as a firefighter and respiratory and nasal symptoms. We observed a highprevalence of asthma-like symptoms in firefighters who presented respiratory symptomsbeginning immediately after firefighting.Conclusion These results suggest that the prevalence of respiratory symptoms and asthmain firefighters is higher than those in police officers. Work-as a firefighter, rhinitis and yearsemployed were risk factors for respiratory symptoms of asthma. Am. J. Ind. Med. 52:261–269, 2009. � 2008 Wiley-Liss, Inc.

KEY WORDS: asthma; firefighters; epidemiology; ECRHS questionnaire; occupa-tional asthma

INTRODUCTION

Firefighting ranks as one of the most dangerous

occupations in the United States [Walton et al., 2003;

Feldman et al., 2004]. The magnitude of the workforce is

considerable, and in Sao Paulo, the largest cities in Brazil and

in South America, there are over 2,500 firefighters. The

city has 11 million inhabitants, an area of 1,500 km2, and

each year about 9,000 fires and 200 dangerous cargo

accidents occur.

� 2008Wiley-Liss, Inc.

1Occupational and Environmental Group, Pulmonary Division, Heart Institute (InCor),University of Sa‹ o Paulo Medical School, Sa‹ o Paulo, Brazil

2Division of Statistics and Epidemiology, Fundacentro, Sa‹ o Paulo, BrazilContract grant sponsor: Pulmonary Division, Heart Institute (InCor), University of Sa‹ o

Paulo Medical School, Sa‹ o Paulo, Brazil.*Correspondence to:Dr.Marcos Ribeiro, Av. Angelica 382 ap 94,01228-000Sa‹ o Paulo, SP,

Brazil. E-mail: marcospneumo@ig.com.br

Accepted 3 November 2008DOI10.1002/ajim.20669. Published online inWiley InterScience

(www.interscience.wiley.com)

Asthma is the most common occupational respiratory

lung disease in industrialized countries as reported from

Canada [Liss et al., 1999], the United States [Matte et al.,

1990], and the United Kingdom [Ross et al., 1998]. Some of

these exposures have been assessed in epidemiological

studies, yet few studies have assessed occupational asthma in

the general population [Tielemans et al., 1999; Tarlo et al.,

2000; Kogevinas et al., 2007]. Studies based on a small

sample of firefighters demonstrated a high risk of disease in

this population [Fosbroke et al., 1997; Liao et al., 2001]. We

neither know relatively little on how individual factors

influence firefighters’ respiratory injuries nor are we clear on

the prevalence of asthma in this population.

We therefore carried out a cross-sectional study using

the European Community Respiratory Health Survey

(ECRHS) questionnaire [Burney et al., 1994] to determine

the prevalence of asthma-related respiratory symptoms in a

population of firefighters from the Sao Paulo State Fire

Department and compared these data with the results from a

group of police officers from the same city.

STUDY POPULATION AND METHODS

A descriptive cross-sectional study was conducted in

firefighters and police officers in Sao Paulo, Brazil. The

Institutional Review Board of the Ethics in Research

Committee of the University of Sao Paulo Medical School

approved the study protocol, and patients gave written

informed consent.

Study Population

The study population was a selection of full-time

professional employees, no administrative personnel of the

Fire Department or Department of Police were included. In

2001 firefighters and police officers were recruited from

the Sao Paulo State Fire Department and the Department

of Police of Sao Paulo City. In Sao Paulo city, 2,500

firefighters are distributed in four regional battalions, and

4,000 police officers are distributed in five regional sections.

Questionnaires were distributed through their regional

command structure to all firefighters (2,200) and police

officers (3,000) who were on duty during 1 week. The

firefighters were involved in different types of jobs

during their work shift (including driving and firefighting)

so they were all exposed to similar unfavorable conditions

during firefighting activities. Each firefighter attended a mean

of 38 fires per year; these rates were stable over the last

5 years.

Firefighters carried a standard firefighter protective

ensemble, which included helmet, hood and gloves, coat

and bunker pants, and leather or rubber boots, depending on

firefighter’s personal preference. Coat and bunker pants are

composite materials (i.e., outer shell, moisture barrier, and

thermal barrier). Firefighters breathed air via self-contained

breathing apparatus (SCBA). The decision to wear the SCBA

and to have the facepiece on depended on the type of

emergency the firefighters were responding to and whether

they were following the standard protocols. There is

limited information about the SCBA function during active

firefighting.

Through their command sections we provided boxes for

questionnaire retrieval. All individuals that were identified as

being eligible for the study were sent this questionnaire with a

cover letter explaining the purpose of the study and its

usefulness; they were advised that the Institutional Review

Board granted approval to conduct the research, and

they were informed that the questionnaire was anonymous

with a discussion on confidentiality. The cover letter

focused on general respiratory health and not on asthma.

We conducted a second mailing in 3 weeks later to non-

respondents with another reminder card 2 weeks after that.

This questionnaire was sent during the same season in

the year and we were uninformed about the identities of the

respondents.

Questionnaire

A self-administered Brazilian-Portuguese translated and

validated version [Ribeiro et al., 2007] of the European

Community Respiratory Health Survey (ECRHS) question-

naire [Burney et al., 1994] was completed (Appendix).

Included in the survey were supplemental questions, not part

of the original ECRHS and developed specifically for the

present study, which sought detailed information about

work-related symptoms, smoking, occupational exposure to

dust, fumes, and gases, and housing. Questions regarding the

presence of these respiratory symptoms—wheezing, dysp-

nea, cough, and rhinitis—after firefighting fires and whether

these symptoms persisted for more than 3 months were also

included in the survey. Finally, information about medication

use was requested.

Patients were divided into ‘‘never-smokers,’’ ‘‘former-

smokers,’’ and ‘‘current smokers’’ and to assess their level of

smoking, the participants were asked about their regular use

of cigarettes in the previous 12 months.

Definition

The definition of asthma was based on the ECRHS

definition from the questionnaire alone. People with current

asthma are defined as having one asthma attack in the

last 12 months and/or current use of asthma medication

[Burney et al., 1994] Adult-onset asthma, reported onset

after starting practice as a firefighter or police officer was

defined as meeting defined symptoms or as diagnosed by a

physician.

262 Ribeiro et al.

Statistical Analysis

The demographic and clinical data are expressed as

mean� SD. We did descriptive analyses and univariate

analysis using a Student’s t-test, the chi-square test or

Fisher’s exact test, and the Cochran–Mantzel–Haenzel test

for risk estimative.

Unconditional multiple logistic stepwise regression

analysis was used to estimate the risk factors associated with

respiratory symptoms. The evaluated independent variables

were smoking, age, gender, years employed, rhinitis and

work as a firefighter. The presence of rhinitis was used as a

dependent and independent variable because this may reflect

the exposition as well as be a cause associated with asthma

symptoms. The statistical analysis was done using SAS 8.01

software (SAS Institute, Inc., Cary, NC). The minimum level

of significance adopted was 0.05.

RESULTS

Questionnaires Returned

Overall, 2,200 and 3,000 questionnaires were distributed

to the firefighters and police officers, respectively. Responses

from 3,635 individuals were completed and returned.

Response rates were 1,480 (67%) for firefighters and 2,155

(72%) for police officers (P¼ 0.86). Responders with

incomplete answers (245 firefighters and 316 police officers)

were excluded from the analysis. We restricted the analysis to

the 1,235 (56%) firefighters and 1,839 (61%) police officers

(P¼ 0.76) that were still working at the time the question-

naire was distributed. It was not possible to send question-

naires to retired individuals.

General Characteristics

There were no significant differences in age between the

groups. The study population comprised more men than

women in both groups, mainly in firefighters (Table I). More

than half of the subjects were never-smokers, and in the group

of firefighters the number of current smokers and former

smokers was higher than in the police officer group

(P< 0.05). The firefighters had worked for a longer amount

of time in their current jobs than the police officers had

(P< 0.05) (Table I).

Respiratory Symptoms

The prevalence of positive answers from firefighters and

police officers and the respective odds ratios are shown in

Table II. The prevalence of symptoms such as wheezing,

wheezing with breathlessness, wheezing without a cold,

waking with tightness in the chest, and rhinitis in firefighters

were significantly higher than those observed in police

officers. The diagnosis of asthma was present in 8.7% of

firefighters and in 7.2% of police officers [OR, 95% CI: 1.21

(0.94–1.54)].

Figures 1–3 present the comparison of asthma symp-

toms among never-smokers and current smokers in male

firefighters and police officers. The male firefighters who

were never-smokers had a higher prevalence for eight of nine

positive answers (OR, 95% CI): wheezing [1.91 (1.52–

2.40)], wheezing with breathlessness [1.58 (1.13–2.22)],

wheezing without a cold [1.77 (1.25–2.52)], waking with

tightness in the chest [1.67 (1.25–2.22)], waking with

breathlessness [1.55 (1.14–2.12)], waking with cough

[1.53 (1.18–1.97)], asthma attack [1.58 (1.00–2.51)] and

rhinitis [1.36 (1.20–1.54)]; and were significantly higher

(P< 0.05) than those in male police officers that were never-

smokers (Figs. 1 and 2).

In male firefighters who were current smokers, the

prevalence was higher in only three out of nine positive

answers: wheezing [1.55 (1.20–2.01)], waking with tight-

ness in the chest [1.67 (1.17–2.40)] and rhinitis [1.40 (1.13–

1.75)] when compared with male police officers that were

current-smokers (Figs. 1 and 3). Meanwhile, the estimated

risk for symptoms was, in general, significantly higher in

male smokers than in male firefighters that were never-

smokers. The diagnosis of asthma in this group was presented

in 9.3% of firefighters and in 6.7% of police officers [OR,

95% CI: 1.23 (1.01–1.56)].

Risk Factors

In a multiple logistic regression, the only independent

risk factors in the development of asthma symptoms

were years employed, smoking, rhinitis, and work as a

TABLE I. General Characteristics of the Study Population (n¼ 3,074)

Firefighters(n¼1,235)

Police officers(n¼1,839)

GenderMale 1,189 (96.3%) 1,279 (69.5%)Female 46 (3.7%) 560 (30.5%)

Age,years=mean (SD) 33 (6.1) 32 (6.6)Years employed,mean (SD) 11.5 (6.0)* 5.9 (5.2)Smoking conditionNever-smokers 685 (55.5%) 1166 (63.4%)Former smokers 225 (18.2%)* 176 (9.6%)Current smokers 277 (22.4%)* 342 (18.6%)Without information 48 (3.9%) 155 (8.4%)

SD, standard deviation.*P< 0.05.

Prevalence of Asthma among Firefighters 263

firefighter. These risk factors were also associated with a high

prevalence of positive answers. Age and gender were not

associated with any of the questions. Table III shows the

results and the respective odds ratio for respiratory symptoms

in both groups.

Rhinitis was an important risk factor related to all

questions, and as a dependent variable it was associated with

the firefighter job (Table III). Work as a firefighter was

associated with a high risk of having symptoms; it doubled

the risk of having wheezing and increased the use of asthma

medications sevenfold.

Reactive Airway SyndromeDisease (RADS)

For the questions regarding RADS and the presence

of wheezing, dyspnea, and coughing immediately after

firefighting, 372 (30%) firefighters answered affirmatively.

TABLE II. Prevalence and ORof Respiratory SymptomsAmong FirefightersVersus Police

QuestionsFirefighters

(n¼1,235) (%)Police officer(n¼1,839) (%) OR (95%CI)

Q1:Wheezing 30.9‰ 17.4 1.63 (1.43^1.87)Q2:Wheezingwith breathlessness 13.2* 9.8 1.34 (1.10^1.64)Q3:Wheezingwithout a cold 14.7‰ 9.2 1.60 (1.32^1.95)Q4:Wakingwithtightness in thechest 17.4* 14.5 1.20 (1.02^1.42)Q5:Wakingwith breathlessness 14.0 12.6 1.12 (0.93^1.34)Q6:Wakingwith cough 19.0 17.8 1.06 (0.92^1.24)Q7: Asthma attack 5.1 4.7 1.22 (0.88^1.68)Q8:Rhinitis 44.5* 39.6 1.12 (1.03^1.22)Q9: Treatment for asthma 7.0 6.5 1.14 (0.87^1.50)Diagnosis of asthmaa 8.7 7.2 1.21 (0.94^1.54)

OR, odds ratio; CI, confidence interval.aDiagnosis of asthma: asthma attack or treatment for asthma.*P< 0.05.‰P< 0.0001.

FIGURE 1. Prevalence of respiratory symptoms amongmale never-smokers and current smokers in the12 months preceding the

survey. *P< 0.005;#P< 0.0001.Q1:Wheezing;Q2:Wheezingwithbreathlessness;Q3:Wheezingwithoutacold;Q4:Wakingwithtight-

ness in the chest; Q5: Wakingwith breathlessness; Q6: Wakingwith cough; Q7: Asthma attack; Q8: Rhinitis; Q9: Treatment for asthma;

Asthma:Q7þ Q9. [Color figurecanbeviewed in theonline issue,which isavailableatwww.interscience.wiley.com.]

264 Ribeiro et al.

FIGURE 2. Oddsratioofrespiratorysymptomsamongmalenever-smokers inthe12monthsprecedingthesurvey.Q1:Wheezing;Q2:

Wheezingwithbreathlessness;Q3:Wheezingwithoutacold;Q4:Wakingwithtightness inthechest;Q5:Wakingwithbreathlessness;Q6:

Wakingwith cough;Q7:Asthmaattack;Q8:Rhinitis; Q9:Treatment forasthma;Asthma:Q7þ Q9. [Color figurecanbeviewedintheonline

issue,which is available atwww.interscience.wiley.com.]

FIGURE 3. Oddsratioofrespiratorysymptomsamongmalecurrentsmokersinthe12monthsprecedingthesurvey.Q1:Wheezing;Q2:

Wheezingwithbreathlessness;Q3:Wheezingwithoutacold;Q4:Wakingwithtightness inthechest;Q5:Wakingwithbreathlessness;Q6:

Wakingwith cough;Q7:Asthmaattack;Q8:Rhinitis; Q9:Treatment forasthma;Asthma:Q7þ Q9. [Color figurecanbeviewedintheonline

issue,which is available atwww.interscience.wiley.com.]

Prevalence of Asthma among Firefighters 265

These symptoms persisted for more than 3 months in 11%

(40 firefighters) or 3.2% of all subjects.

DISCUSSION

We examined the prevalence of respiratory and nasal

symptoms among firefighters and police officers using the

ECRHS questionnaire in a large population-based cross-

sectional study of adults in Sao Paulo City, Brazil.

Our study demonstrates a moderate effect of hazardous

environmental conditions on the respiratory system of the

firefighters. In these subjects a high prevalence of respiratory

symptoms were recorded for rhinitis, wheezing, waking with

tightness in the chest, wheezing without a cold, and wheezing

with breathlessness. The strengths of our study were in its

relatively large sample group; a relatively good response rate;

a similar response rate between the two groups; and in our

ability to control possible confounders such as age and

smoking.

Our data show that the prevalence of adult asthma in

never-smokers was 9.3% in firefighters and 6.7% in police

officers [(OR, 95% CI: 1.23 (1.01–1.56)]. In the firefighters,

an independent association was observed regarding the years

employed, smoking, rhinitis, and respiratory symptoms that

began immediately after firefighting and were associated

with a higher prevalence of respiratory symptoms. These

differences were more significant in the never-smoking

firefighter group, suggesting an associated occupational

factor.

The multiple logistic regressions showed that having

rhinitis, working as a firefighter and the number of years

employed were the factors most strongly associated with a

higher risk of having respiratory symptoms. The smoking

condition showed a mild effect and it occurred in only four

out of the nine questions in our questionnaire. The number

of years employed is an influential factor that most likely

reflects chronic and/or successive exposure; rhinitis is

closely associated with asthma; and chronic cough and work

as a firefighter showed a higher risk of symptoms for the

majority of our questions.

Prevalence of occupational asthma (OA) in an adult

asthmatic population has varied in published studies and

ranges from 6% to 17% depending on the definition used

[Blanc et al., 1996; Nicholson et al., 2005; Kogevinas et al.,

2007]. One of the major strengths of our study is that it is

population-based, unlike other OA studies [Tielemans et al.,

1999; Johnson et al., 2000]. We found a prevalence of work

related asthma for 8.7% of firefighters in the population

studied.

There have been few prevalent studies of asthma and

asthma-like symptoms among adult firefighters that use a

standardized questionnaire [Rothman et al., 1991; Betchley

et al., 1997; Mustajbegovic et al., 2001; Miedinger et al.,

2007a,b] and none that use the ECRHS questionnaire

exclusively. Some studies [Rothman et al., 1991; Betchley

et al., 1997; Mustajbegovic et al., 2001] found an increase in

one or more respiratory symptoms associated with recent

fire-suppression activities. Others [Miedinger et al., 2007a,b]

found that there was an increased risk of acute and chronic

respiratory symptoms and obstructive airway changes in

active firefighters.

A number of possibilities could explain the high

prevalence of respiratory and nasal symptoms despite

the use of cartridge respirators. First, certain products of

combustion, such as carbon monoxide, free radicals, or hot

dry air, may not be effectively absorbed by the cartridges. An

alternative hypothesis is that the use of cartridge respirators

in a negative pressure mode could cause changes in the

absence of chemical exposure. Another possibility is that

there was variable compliance and variable effectiveness of

use the respirators. Although the availability and effective-

ness of protective devices such as SCBA [Guidotti and

TABLE III. Risk Factors AssociatedWith Respiratory SymptomsFromMultiple Logistic Regressions for Study Population OR (95% CI)

Questions Years employed Smoking Rhinitis Work as a firefighter

Q1:Wheezing 1.44 (1.20^1.74) 1.05 (1.03^1.07) 5.96 (4.72^7.56) 2.20 (1.67^2.91)Q2:Wheezingwith breathlessness 1.32 (1.00^1.74) = 4.56 (3.18^6.74) 1.81 (1.30^2.53)Q3:Wheezingwithout a cold 1.29 (0.98^1.70) 1.04 (1.02^1.07) 2.64 (1.87^3.77) 3.69 (2.47^5.60)Q4:Wakingwithtightness in thechest 1.61 (1.31^1.98) 1.03 (1.01^1.06) 4.56 (3.50^5.97) 1.25 (0.93^1.70)Q5:Wakingwith breathlessness 1.74 (1.32^2.30) = 6.57 (4.81^9.11) 2.82 (1.77^4.47)Q6:Wakingwith cough 1.26 (1.04^1.53) 1.03 (1.01^1.05) 4.10 (3.23^5.24) =Q7: Asthma attack = = 7.03 (4.99^13.27) =Q8:Rhinitis 1.20 (1.00^1.45) = = 1.35 (1.13^1.62)Q9: Treatment for asthma = = 7.94 (4.99^13.27) 7.89 (4.18^15.33)Diagnosis of asthmaa = = 6.57 (4.41^10.12) 1.25 (0.87^1.76)

OR, odds ratio; CI, confidence interval.aDiagnosis of asthma: asthma attack or treatment for asthma.

266 Ribeiro et al.

Clough, 1992] has increased, SCBA is insufficiently used by

firefighters due to its weight and inconvenience [Burgess

et al., 2001], especially when smoke is not visible and during

phases of overhaul or work in the second line (drivers, pump

manipulators), when important exposure to combustion

products may persist. The appropriate equipment is often

not used during the overhaul and clean-up phase after visible

flames are extinguished despite the possible high concen-

tration of combustion products even during this phase.

The majority of symptoms reported by the firefighters in

the present study were relatively mild complaints related

to irritation of the respiratory tract. These findings are

consistent with previous studies that have shown an increase

in respiratory symptoms, including nasal irritation, cough,

and sputum production and wheezing [Rothman et al., 1991;

Betchley et al., 1997; Mustajbegovic et al., 2001; Miedinger

et al., 2007a,b]. The clinical importance of this respiratory

irritation may be minor in the present study population,

which was comprised of health subjects with no underlying

respiratory conditions. However, in ‘‘at-risk’’ subjects with

conditions such as asthma and chronic obstructive pulmo-

nary disease, this upper and lower respiratory tract irritation

may be sufficient to exacerbate the lung condition.

Differences in findings of the frequency and severity of

respiratory problems among firefighters, also is probably the

result of different methods used in the many studies, different

populations studied (possibly sensitivity of the studied

subjects), different types of smoke that firefighters are

exposed to, as well as the frequency in the use of protective

equipment.

No information is available on facepiece fit for fire-

fighters in Sao Paulo. It is possible that the extent of adverse

health effects seen in Sao Paulo could be reduced if optimal

facepiece fit were achieved.

Duration of actual firefighting employment represents

an improvement over total duration of employment as an

index of exposure, but is still likely to be a poor surrogate for

dose to specific agents. Firefighters vary in the number of fires

they fight and exposures may vary greatly among fires.

Employment information was ascertained from fire depart-

ment records and without knowledge of disease outcome.

Therefore, exposure misclassification resulting from the

individual differences is likely to be no differential, which

potentially resulted in an under-ascertainment of exposure

effect. However, it is difficult to assess the magnitude of any

potential bias without a better measure of exposure.

An important strength of the investigation is our control

group, the police officers. Both firefighters and police officers

perform full-time work, and it is presumed that the police

have a very limited or no exposure compared with fire-

fighters, because they do not work in fire zones. Police

officers and firefighters have similar demographic charac-

teristics with respect to socioeconomic status, access to

healthcare, retirement benefits, and physical entry require-

ments, and they have been used in epidemiological studies

before [Kern et al., 1993; Burgess et al., 2003].

The Sao Paulo State Fire Department firefighter

population is selected for physical fitness without respiratory

pathology (which include a complete respiratory and cardi-

ovascular examination), and also regular medical examina-

tion when in service to confirm the status ‘‘fit for duty.’’ It

can be argued that although having asthma, these asthmatic

firefighters are still in the active workforce and are

therefore not suffering from a clinically relevant asthma.

Fire Department is not allowed to perform challenge tests in

asymptomatic candidates who have a negative respiratory

history, due to the discriminatory impact of false-positive test

results.

The results seen in our study probably reflect, in part, the

healthy worker effect. This is plausible because firefighters

are generally very fit individuals, accustomed to high levels

of exertion as well as selection factors within the fire

department (company transfers, promotion, and retirement).

Therefore, there is a possibility of under-reporting symptoms

during medical screening of firefighters. Potential under-

reporting of symptoms and the current diagnosis of asthma

have been reported in USA Air Force recruits [Nish and

Schwietz, 1992]. The findings of the present study underline

the value of performing objective questionnaires prior to

enrolment and also during routine medical examination of

firefighters. Seasonal as well as retired firefighters were not

included in this study. Further studies are needed to evaluate

the influence of asthma on the work performance of retired

firefighters.

It is important to perform periodic evaluations to

identify asthma and rhinitis early among firefighters. A

smoking cessation program should also be developed,

especially among firefighters. The use of symptoms to

identify workers who are potentially at a higher risk of

pulmonary impairment has been recommended for asbestos-

exposed workers [Brodkin et al., 1993] and may be an

efficient method of monitoring workers recently exposed to

smoke when pulmonary function testing is unavailable. A

reliable and validated standard respiratory questionnaire still

needs to be developed for acute symptoms and could be

useful for studies of firefighters.

In conclusion, we observed that work as a firefighter is an

independent risk of asthma and nasal symptoms. The next

step is to perform a cohort study with the same or other

control group.

ACKNOWLEDGMENTS

The authors would like to thank the Sao Paulo State Fire

Department and the Department of Police of Sao Paulo City.

Thanks also to the Pulmonary Division, Heart Institute

(InCor), University of Sao Paulo Medical School, Sao Paulo,

Prevalence of Asthma among Firefighters 267

Brazil and the Division of Statistics and Epidemiology,

Fundacentro, Sao Paulo, Brazil.

APPENDIX

To answer the questions please choose the appropriate

box. If you are unsure of the answer please choose ‘‘NO’’

1. Have you had wheezing or whistling in your chest at

any time in the last 12 months?

IF ‘‘NO’’ GO TO QUESTION 2, IF ‘‘YES’’:

1.1. Have you been at all breathless when the wheezing

noise was present?

1.2. Have you had this wheezing or whistling when you did

not have a cold?

2. Have you woken up with a feeling of tightness in your

chest at any time in the last 12 months?

3. Have you been woken by an attack of shortness of

breath at any time in the last 12 months?

4. Have you been woken by an attack of coughing at

any time in the last 12 months?

5. Have you had an attack of asthma in the last 12 months?

6. Are you currently taking any medicine (including

inhalers, aerosols or tablets) for asthma?

7. Do you have any nasal allergies including hay fever?

8. What is your date of birth?

9. What is today’s date?

10. Are you male or female?

REFERENCES

Betchley C, Koenig JQ, van Belle G, Checkoway H, Reinhardt T. 1997.Pulmonary function and respiratory symptoms in forest firefighters. AmJ Ind Med 31:503–509.

Blanc PD, Cisternas M, Smith S, Yelin E. 1996. Occupationalasthma in a community-based survey of adult asthma. Chest 109:56S–57S.

Brodkin CA, Barnhart S, Anderson G, Checkoway H, Omenn GS,Rosenstock L. 1993. Correlation between respiratory symptoms andpulmonary function in asbestos-exposed workers. Am Rev Respir Dis148:32–37.

Burgess JL, Nanson CJ, Bolstad-Johnson DM, Gerkin R, Hysong TA,Lantz RC, Sherrill DL, Crutchfield CD, Quan SF, Bernard AM, WittenML. 2001. Adverse respiratory effects following overhaul in fire-fighters. J Occup Environ Med 43:467–473.

Burgess JL, Witten ML, Nanson CJ, Hysong TA, Sherrill DL, Quan SF,Gerkin R, Bernard AM. 2003. Serum pneumoproteins: A cross-sectional comparison of firefighters and police. Am J Ind Med 44:246–253.

Burney PG, Luczynska C, Chinn S, Jarvis D. 1994. The EuropeanCommunity Respiratory Health Survey. Eur Respir J 7:954–960.

Feldman DM, Baron SL, Bernard BP, Lushniak BD, Banauch G,Arcentales W, Kelly KJ, Prezant DJ. 2004. Symptoms, respirator use,and pulmonary function changes among New York City firefightersresponding to the World Trade Center disaster. Chest 125:1256–1264.

Fosbroke DE, Kisner SM, Myers JR. 1997. Working lifetime risk ofoccupational fatal injury. Am J Ind Med 31:459–467.

Guidotti TL, Clough VM. 1992. Occupational health concerns offirefighting. Annu Rev Public Health 13:151–171.

Johnson AR, Dimich-Ward HD, Manfreda J, Becklake MR, Ernst P,Sears MR, Bowie DM, Sweet L, Chan-Yeung M. 2000. Occupationalasthma in adults in six Canadian communities. Am J Respir Crit CareMed 162:2058–2062.

Kern DG, Neill MA, Wrenn DS, Varone JC. 1993. Investigation of aunique time-space cluster of sarcoidosis in firefighters. Am Rev RespirDis 148:974–980.

Kogevinas M, Zock JP, Jarvis D, Kromhout H, Lillienberg L, Plana E,Radon K, Toren K, Alliksoo A, Benke G, Blanc PD, Dahlman-HoglundA, D’Errico A, Hery M, Kennedy S, Kunzli N, Leynaert B, MirabelliMC, Muniozguren N, Norback D, Olivieri M, Payo F, Villani S, vanSprundel M, Urrutia I, Wieslander G, Sunyer J, Anto JM. 2007.Exposure to substances in the workplace and new-onset asthma: Aninternational prospective population-based study (ECRHS-II). Lancet28:336–341.

Liao H, Arvey RD, Butler RJ, Nutting SM. 2001. Correlates of workinjury frequency and duration among firefighters. J Occup HealthPsychol 6:229–242.

Liss GM, Tarlo SM, Banks D, Yeung KS, Schweigert M. 1999.Preliminary report of mortality among workers compensated for work-related asthma. Am J Ind Med 35:465–471.

Matte TD, Hoffman RE, Rosenman KD, Stanburg M. 1990. Surveil-lance of occupational asthma under the SENSOR model. Chest 98:173S–178S.

Miedinger D, Chhajed PN, Tamm M, Stolz D, Surber C, Leuppi ID.2007a. Diagnostic tests for asthma in firefighters. Chest 131:1760–1767.

Miedinger D, Chhajed PN, Stolz D, Gysin C, Wanzenried AB, SchindlerC, Surber C, Bucher HC, Tamm M, Leuppi JD. 2007b. Respiratorysymptoms, atopy and bronchial hyperreactivity in professional fire-fighters. Eur Respir J 30:538–544.

Mustajbegovic J, Zuskin E, Schachter EN, Kern J, Vrcic-Keglevic M,Heimer S, Vitale K, Nada T. 2001. Respiratory function in activefirelighters. Am J Ind Med 40:55–62.

Nicholson PJ, Cullinan P, Newman Taylor AJ, Burge PS, Boyle C. 2005.Evidence based guidelines for the prevention, identification, andmanagement of occupational asthma. Occup Environ Med 62:290–299.

Nish WA, Schwietz LA. 1992. Underdiagnosis of asthma in youngadults presenting for USAF basic training. Ann Allergy 69:239–242.

Ribeiro M, Angelini L, Robles-Ribeiro PG, Stelmach R, Santos UdeP,Terra-Filho M. 2007. Validation of the Brazilian-Portuguese version ofthe European Community Respiratory Health Survey in asthmapatients. J Asthma 44:371–375.

Ross DJ, Keynes HL, McDonald JC. 1998. SWORD 97: Surveillance ofwork-related and occupational respiratory disease in the UK. OccupMed 48:481–485.

268 Ribeiro et al.

Rothman N, Ford DP, Baser ME, Hansen JA, O’Toole T, Tockman MS,Strickland PT. 1991. Pulmonary function and respiratory symptoms inwildland firefighters. J Occup Med 33:1163–1167.

Tarlo SM, Leung K, Broder I, Silverman F, Holness DL. 2000.Asthmatic subjects symptomatically worse at work: Prevalence andcharacterization among a general asthma clinic population. Chest 118:1309–1314.

Tielemans E, Heederik D, Burdorf A, Virmeulen R, Veulemans H,Kromhout H, Kartog K. 1999. Assessment of occupational exposures ina general population: Comparison of different methods. Occup EnvironMed 56:145–151.

Walton SM, Conrad KM, Furner SE, Samo DG. 2003. Cause, type, andworkers’ compensation costs of injury to fire fighters. Am J Ind Med43:454–458.

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