Clean your kit

Dermal absorption of toxic chemicals on PPE is elevating firefighters’ risk of developing cancer, according to a new study from the University of Central Lancashire in the UK. But what can be done to minimise this risk? Lotte Debell looks at research and initiatives from around the world and the challenges faced by fire services in getting to grips with the cancer threat.

Professor Anna Stec, lead researcher on the UCLAN study.

Dirty gear is still regarded as a badge of honour by some fireighters, but awareness of the health risks is now on the increase. (Shutterstock)

Cancer is the leading cause of death for firefighters. A search of the IAFF line-of-duty death database for cancer brings up 1,762 names. The organisation’s Fallen Firefighter Memorial Wall of Honour, erected more than 30 years ago in Colorado to honour firefighters from the US and Canada, has more than 7,600 names in total. 190 names were added in 2017. 167 were deaths caused by cancer. In fact, cancer accounts for more than 60% of the names added in the last five years.

Study after study has shown that firefighters are at an increased risk of developing cancer because of the toxins they are exposed to on the job. But for many firefighters it doesn’t take a study to tell them what they already know – that too many of their colleagues have died from, or are fighting, cancer.

The studies point to exposures to toxic compounds during fire suppression as the reason for a firefighter’s elevated risk of developing cancer. But what is becoming clearer as more research is coming out is how this exposure is happening. Whereas for a long time, the focus had been on inhalation, current research suggests dermal absorption is the main culprit – and this raises serious questions about how firefighters can protect themselves from this potentially deadly occupational hazard.

The most recent study to provide evidence of the dangers of dermal absorption of chemicals from combustion was conducted by the University of Central Lancashire in the UK[1]. Published in February 2018 in Nature’s Scientific Reports, it is the first study of its kind in the country and links a firefighter’s increased risk of cancer to ‘dangerously high levels of harmful chemicals’ on their PPE after exposure to smoke from a fire. It also highlighted the need for government intervention and regulation for the long-term health protection of firefighters.

Astonishingly, despite the growing evidence, firefighting is not currently considered a high-risk occupation in Europe. Following a meeting at the European Parliament to discuss fire toxicity and firefighter health, the study’s lead researcher Professor Anna Stec – who has been arguing for years that the risks are much higher than anyone in the fire service acknowledged – realised that more data was required to demonstrate firefighters’ exposure to carcinogenic chemicals.

"We know that firefighters are exposed to a cocktail of acute toxins – those that have an immediate effect – as well as chronic toxins, which have a long-term effect. Within chronic toxins, not a lot of research has been carried out."

For this reason, the study focused exclusively on PAHs (polycyclic aromatic hydrocarbons), specifically on 16 that are classed as either carcinogenic, potentially carcinogenic or possibly carcinogenic by the US. "Acute toxins will depend on the fire conditions and fuel for any given fire, but soot is carbon and everything contains carbon. So, we decided to focus on soot because it is always present and it sticks to everything. Soot is a build-up of PAHs."

While conversations about exposure have tended to focus on inhalation, Stec took a different route. Since the use of breathing apparatus should limit the inhalation risk, and with studies from the US showing the presence of particulates under firefighters’ clothing, the UCLAN team homed in on clothing contamination and potential exposure on the skin. They also looked at PPE cleaning methods – or lack of them – and their effectiveness.

This is really one of the key issues. If PPE is contaminated with carcinogens and is not cleaned effectively or indeed at all between incidents, the chemicals on those garments can cause repeated exposures for the firefighters who wear them, as well as potentially contaminating vehicles and anything else they touch.

Working with 136 firefighters from two fire stations during training scenarios, researchers took pre- and post-event wipe samples from firefighters’ skin and PPE as well as from their workspace and fire engines, taking account of differences in PPE storage methods between the two stations. They looked at various roles, from instructors to trainees, and most, if not all, had carcinogens on their clothing and skin.

"When we calculated the cancer risk to firefighters within 30 to 40 years of exposure to these contaminants on their clothing – and not washing that clothing – it is very high," said Stec. In fact, she says, it is as much as 350 times higher than the level that would prompt government intervention in the US.

"Many firefighters have told us that they don’t have the facility to clean their kit at the station, so they either take it home to wash it or don’t wash it at all. And they often leave it in rooms close to their offices and sleeping areas. Most fire services in

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The UCLAN study looked at various roles from instructors to trainees, and found that most, if not all, had carcinogens on their clothing and skin after a fire. (Shutterstock)

the UK have no regulations on how they clean their kit and based on the samples we collected, there is clear evidence that clothing is not being effectively decontaminated."

This is a story that is being repeated around the world. A study from the US by Kenneth Fent et al[2], published in 2017 in The Journal of Occupational and Environmental Hygiene, found PAHs on firefighters’ PPE, necks and hands at varying concentrations depending on their role during an incident, and that levels of the chemicals on PPE increased after each fire. While the study did not measure biomarkers of PAHs, since these are readily absorbed through the skin, the authors concluded that firefighters in the study likely experienced biological uptake of these chemicals.

In Europe, researchers in Belgium identified a risk from PPE when firefighters kept isolated in a room wearing their turnout gear for four hours showed evidence of increased toxin levels in urine samples. Belgian company Decontex has since developed a full decontamination programme for fire PPE – chemical, biological and particle (asbestos) decontamination – based on the LCO2 extraction technology, to ensure that harmful compounds are effectively removed.

But it’s not simply a case of cleaning PPE. It’s also about persuading firefighters that this needs to happen. And that is not nearly as easy as it sounds.

"A few years ago in Belgium, a survey asked firefighters how often they clean their gear, and most said never or once a year," says Tommy Verminck, who set up Decontex. "Why is that? Because they don’t have the facility, or they just don’t want to? Testosterone is a real problem here."

Or, as Lieutenant Heather Buren from the San Francisco Fire Department puts it: "The dirtier your gear, the saltier, hardier firefighter you are."

For the last few years, Buren has been working to educate firefighters in her department and around the US on the need for post-event decontamination and the risk of cancer as part of her work on the Women Firefighters Biomonitoring Study (WFBS) looking specifically at breast cancer risk. Behaviour change is happening, she says, but it is a slow process – even when it is mandated from the top.

"As firefighters, in order to cope with all the things we do and see on the job, we separate ourselves from it. We look at all this death and mayhem and say 'that won’t happen to me'. Especially for those who have been in the service a long time, cleaning kit goes against the grain of what it means to be a firefighter. All these things conspire to make behaviour change difficult."

The WFBS made a video using shaving cream to visually

represent PPE contamination. It’s an extremely effective demonstration of why decon is necessary – and just how easy it is to transfer contamination from PPE to skin, to vehicles, and even to homes. "We also held a memorial for fallen firefighters by putting the boots of all those who have died from cancer on the steps of city hall – 250 pairs of boots. That’s something you can’t look away from and say it isn’t happening. But, fire departments are steeped in tradition. Even when a general order is issued, it’s a slow trickledown. You can mandate change, but that’s just not how it works in the service. It is going to take time."

"In Europe, unions have been a driving force behind behaviour change," says Tommy Verminck. "In Belgium, the union published cartoons, organised conferences and produced videos to explain the risks of taking contaminated clothing home. They also lobbied for legislation."

In Australia, a campaign by the United Firefighters Union of Australia pushed for the introduction of presumptive legislation that recognises certain cancers in firefighters as having an occupational cause, making them eligible for compensation. In 2011, this campaign contributed to the passing of the Fair Protection for Firefighters Bill by the Australian Federal Parliament. The UFUA is now continuing the campaign at state level.

Presumptive cancer laws – laws that contain the presumption that certain cancers are a result of occupation rather than requiring the person to prove this – are hugely important in countries like the US, where they make it easier for firefighters diagnosed with cancer to claim paid medical, disability pensions and benefits for their families after death.

The inclusion of breast cancer in presumptive legislation across the US was a motivating factor for the Women Firefighters Biomonitoring Study in San Francisco. In December 2017, the provincial government of Alberta, Canada, became the first Canadian jurisdiction to add two female-specific cancers – ovarian and cervical – to its list of site-specific presumptive cancers for firefighters. It also lowered the exposure period for testicular cancer.

Presumptive laws are all very well, and undoubtedly necessary in those countries where lack of them might mean that firefighters with occupational cancers cannot receive the help and benefits they need. But what, if anything, can governments and regulators and the fire service itself do to reduce the risk?

"There are now more than enough studies that show the risk is real," says Verminck. "What the industry needs to do now – and what the fire service is notoriously bad at doing – is move from the problem to the solution."

But what does that solution look like? Is it behavioural, regulatory, technological, or all three? Verminck’s message, that it is time to stop talking and start doing, is not aimed solely at the fire service. Industry also needs to come together. "Instead of the detergent makers, machine makers, and PPE suppliers all doing their own thing, they should come together to find a solution," says Verminck. "Then they could create the best suits that could be cleaned by the best detergents, using the best technology. And the fire service should undertake to use what they develop because it is not traditionally an early adopter of technology and so industry has been reluctant to invest."

The increase in cancer deaths since the 1970s has been blamed on changes in modern building materials and home furnishings, including the rise of synthetic materials and plastics and even flame-retardant coatings for household goods. If the increasing toxicity of the smoke from fires is partly to blame, is this an area where future regulation could make a difference? "There is a gap between the public perception of what a

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firefighter’s job is and the reality," said Peter Maes, firefighter and emergency medical technician with the Brussels Fire Department, speaking at the same European Parliament meeting that Anna Stec attended. "Being a firefighter is never running through fire: it is crawling through thick smoke. The smoke is hot, it is flammable, it is blinding. It is also increasingly toxic, and only a small amount of material can create a huge amount of smoke."

Stec said: "The EU needs to admit there is a problem and act to regulate smoke toxicity. I am hopeful that my research, and the research of those feeding into the European Parliament’s roundtable discussions, will be influential in that outcome."

However, even if regulations on smoke toxicity did come into effect – and in the EU at least that is not likely to happen any time soon – soot would still be present at every fire and so would PAHs. These chemicals would still adhere to PPE and potentially contaminate a firefighter’s skin. Likewise, while manufacturers and standards agencies are looking into changes to PPE design to reduce chemical exposure, and though these changes might offer some benefits, the PPE would still get dirty and it would still need cleaning.

"At the end of the day, firefighting is a risky business. We can’t control what happens in the fire," says Lt Buren. "As firefighters, we are not going to refuse to go into a fire because it looks toxic. But what we do before and after a fire is within our control, and there are things we can do to prevent us from becoming cancer statistics."

In San Francisco, cleansing wipes are starting to appear on fire trucks. These can be used by firefighters to wipe down key areas such as the neck, hands, and groin after a fire. The 2017 Fent et al study found that use of cleansing wipes can reduce skin contamination by PAHs on the neck by a median of 54%. The same study looked at three methods of field decontamination and concluded that wet soap decon was the most effective.

Then there’s proper decontamination and PPE cleaning procedures. In San Francisco, special washing machines called extractors were installed in stations several years ago and are now in almost half of the city’s firehouses – although it took a while to persuade firefighters to use them. "Even before that we began an effort to get turnout gear out of sleeping dorms and common rooms because people were just wearing their dirty gear all over the station," says Buren.

"It’s about individual responsibility. I can sit back and say my department should do this and that to protect me, and that’s certainly true, but it has to start at an individual level."

Technology can build on mitigation efforts through behaviour change. There’s a project underway at the Catholic University Leuven in Belgium to create a health-monitoring patch for firefighters that detects when it has become saturated with harmful chemicals, triggering further tests and the potential for firefighters to be taken out of active service for a period to control exposure and risk levels. The project, which is still very much in development, could also include an app that could enable firefighters to monitor their own health, including activity, temperature and chemical exposures, which could encourage individuals to take greater responsibility for their own health.

And when there are so many layers of responsibility involved, from government to manufacturers to fire services, Buren is right: firefighters cannot afford to wait on others to change things. Which does not mean that change shouldn’t also come from other directions and for everyone else involved in this fight, the growing awareness and increasing number of conversations about firefighters and cancer are crucial steps in the right direction. But it is going to take everyone working together to turn it around.

References

1 Occupational exposure to polycyclic aromatic hydrocarbons and elevated cancer incidence in firefighters. Anna A Stec et al. http://rdcu.be/GnmR

2 Contamination of firefighter personal protective equipment and skin and the effectiveness of decontamination procedures Kenneth W. Fent et al. https://www. tandfonline.com/doi/abs/10.1080/15459624.2017.1334904

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