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

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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.

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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

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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

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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

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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]

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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)

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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

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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

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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.

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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

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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

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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

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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

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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).

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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

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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

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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

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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.

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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.

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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].

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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

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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

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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: pmalassigne@sdis36.org

2Operations Assistant Director, Fire Safety, Levis City, Polytechnique School, Montreal;

National School of Public Health of Quebec, Quebec, Canada, email:

ramnotte@hotmail.com

3Médecin du travail, évaluateur SQVT, AFNOR, France, e-mail: lembeye@orange.fr

4Anesthesiologist Resuscitator, Emergency Department/SMUR, Emergency Response

Plans, University Hospital Center, Liege, Belgium, email: l.bodson@chu.ulg.ac.be

5Occupational Doctor, Fire Department, Autonomous Region of Madrid, Spain, email:

cifuentesblanca@gmail.com

6Doctor in Civil Engineering, Lt. Colonel of firefighters, Responsible for Civil Protection

at the Interministerial Staff, Region of Lyon, France, email: pierre.garioud@orange.fr

7Doctor-Engineer in Chemistry ECM, Director of Scientific Affairs, Laboratoire

PREVOR, France. Moulin de Verville, 95760 Valmondois, France, email:

lmathieu@prevor.com

8 Health executive, head nurse health service and medical emergency firefighters, Landes

SDIS, France, email: dominique.morincome@wanadoo.fr

9Occupational Doctor and Toxicologist, Department of Preventive Medicine, Saint-

Etienne; Poison Center and Toxicovigilance, Lyon, France, email: fortin.jean-

luc@wanadoo.fr

10Associate Dean for Research and Professor, Mel and Enid Zuckerman College of Public

Health, University of Arizona, Tucson, AZ, USA, email: jburgess@email.arizona.edu

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:

OldEDDoc@gmail.com.

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: OldEDDoc@gmail.com

I no longer support FAX.