Much has been written about the current scourge of firefighting that is cancer. Support networks and research institutions are evolving from coast to coast while several states although slow to get their act together are beginning to develop and pass firefighter cancer presumptive legislation. In June of this year, a short article, “Seven Simple Cancer-Free Habits (see below) based on The Lavender Report was published in the Pennsylvania Fireman, which addressed simple practices firefighters can adopt to help minimize the risks of cancer. I struggled with this article attempting to present another view regarding the dangers of and solutions for the cancer threat.
Simply stated: a prime contributor to the most common causes of cancer is the exposure to per- and poly-fluoroalkyl substances – PFAS for short. This is not to ignore or minimize the effects that the hundreds (perhaps thousands) of combustion byproducts and other hazardous substances firefighters come into contact with, the intent is simply to lay out a sort of PFAS-101. Other articles, studies and commentaries are cropping up and available for consumption and should be incorporated in this effort to educate oneself.
As you read this, you may start piecing the puzzle together that shows how the fire service quite innocently got tangled up in the current battle for the health and wellness of its members and the presence of PFAS in the tools first responders rely on, and the products they and their loved ones come into contact within everyday life.
This is not a chemistry lesson or in-depth technical cause-and-effect report. I’m not a fan of chemistry…or hazardous materials for that matter. Me explaining chemistry is like a truckie explaining which end of the hose water exits.1 Nonetheless, I press on.
A somewhat detailed PFAS discussion is found on the CDC website Agency for Toxic Substances and Disease Registry (ASTDR) describing PFAS as a group of unique chemically stable manmade compounds2 that have been used in industry and consumer products worldwide since the 1950s. Although the list of products and uses number in the thousands, a brief listing includes nonstick cookware, water-repellent clothing, stain resistant fabrics and carpets, some cosmetics, some firefighting foams, firefighting and first responder personal protective equipment (PPE) and products that resist grease, water, and oil.
WARNING – CHEMICAL STUFF: The most commonly studied PFAS are perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). The next most commonly studied are perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA).
PFOA and PFOS have been phased out of production and use in the United States, but other countries may still manufacture and use them in products we import.
During production and use, PFAS can migrate into the soil, water, and air. (Read THIS JUST IN at the bottom.) Most PFAS (including PFOA and PFOS) do not break down, so they remain in the environment. As reported in the ASTDR, “Because of their widespread use and their persistence in the environment, PFAS are found in the blood of people and animals all over the world and are present at low levels in a variety of food products and in the environment.” Some PFAS can build up in people and animals with repeated exposure over time contributing to the occurrence of cancer and other serious health issues.
Here is the confusing part of the PFAS journey: Although many scientific articles have been published about PFAS exposure and health effects it is difficult to show that substances directly cause detrimental health conditions in humans, scientific studies have shown that exposure to some PFAS in the environment may be linked to harmful health effects in humans and animals. More research is needed to better understand the health effects of PFAS exposure. However, it is through the continued dogged advocacy of firefighter and first responder organizations that the problems of PFAS exposure are remaining in the minds and efforts of legislators – and now manufacturers and suppliers.
GENERAL EXPOSURE TO PFAS
- Drinking contaminated municipal water or private well water
- Food grown or raised near places that used or made PFAS
- Eating fish caught from water contaminated by PFAS (PFOS, in particular)
- Accidentally swallowing contaminated soil or dust
- Eating food packaged in material that contains PFAS
- Using products such as stain resistant carpeting and water repellent clothing.
Industrial use includes plumbing products that join and clean metals, fluoroplastic layers to create fire-resistant clothing, paper products for coatings to repel moisture and grease, such as nonfood paper packaging and food contact materials such as pizza boxes and fast-food wrappers and wire manufacturing for coating and insulation.
As reported by the CDC, the most commonly studied PFAS are perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). The next most commonly studied are perfluoro hexane sulfonic acid (PFHxS), and perfluoro nonanoic acid (PFNA). These compounds are no longer made in the United States and have been replaced with alternative PFAS, such as GenX chemicals.
Studies of laboratory animals given large amounts of PFAS indicate that some of these probable carcinogens may affect growth and development. In addition, these animal studies indicate PFAS may affect reproduction, thyroid function, the immune system, and injure organs such as the liver. Epidemiologic studies on PFAS exposure evaluated several health effects. Descriptions of these studies are available at: https://www.atsdr.cdc.gov/pfas/. Research is continuing to assess the human health effects of exposure to PFAS.
HISTORY OF PFAS USE IN FIREFIGHTING
On 29 July 1967, the aircraft carrier USS Forrestal experienced a catastrophic fire resulting in 134 dead sailors and 161 injured crew members. Shortly after the incident, scientists developed a firefighting product containing a PFAS foam mixture commonly known as aqueous film forming foam or AFFF. It was highly effective combatting flammable liquid fires and was installed at all military aircraft units and installations, civilian airports and adopted by municipal fire departments throughout the US.
AFFF has been the industry standard for combatting liquid fuel fires and hazards for almost 50 years. AFFF is a water-based solution that contains a fluorinated, film forming surfactant to seal the fuel surface during suppression and extinguishment.
Although the PFAS family had been around since the 1930s, its use and popularity took off following the adoption by the US military and other large-scale users. Today, thousands of products containing PFAS are used for everyday consumption including thousands of firefighting bunker gear sets, firefighting foams and assorted fire-retardant products.
As stated above, although PFOA and PFOS have been phased out of production and use in the United States, other countries may still manufacture and use them. Keep this in mind when your department considers product purchases from companies who operate (PFAS) manufacturing plants or use suppliers out of the United States.
(Several of the following details and recommendations are based on the NFPA publication Firefighting Foams: Fire Service Roadmap)
MINIMIZING FIREFIGHTER EXPOSURES
There is a double-edged sword regarding the need to limit exposure to PFAS and the need to protect firefighters and first responders when performing their duties. Read on.
Although not always strictly enforced, for decades it has been recommended that firefighters (and other emergency response personal) wear proper personal protective equipment (PPE) when there is a risk of exposure to AFFF. This equipment should be properly fitted, worn, maintained and ultimately decontaminated after exposure to AFFF.
Firefighters face additional PFAS exposure risks due to the use of remaining inventories of PFAS-containing AFFF in training and firefighting foam applications. Handling, training and emergency use of AFFF exposes emergency personnel to PFAS through ingestion, inhalation or dermal absorption. AFFF contains fluorinated, film forming surfactants (per- and poly- fluoroalkyl substances (PFAS)) to seal the fuel surface during suppression/extinguishment. All AFFFs (as well as all other fluorinated firefighting foams) contain PFAS. Firefighters can also be exposed to PFAS through the combustion of PFAS-containing products (e.g., carpets, upholstery, etc.).
Additionally, firefighters can be exposed to PFAS via turnout gear. PFAS have been used in water-repellent fabrics in all layers of gear to provide water-resistance and to protect firefighters from steam. Some States have passed additional regulation for PFAS in firefighting PPE and there is ongoing research to determine the risks of PFAS exposure through turnout gear.
There is only limited information quantifying the long-term health effects of foam exposures on firefighters. The Centers for Disease Control and Prevention (CDC) have also conducted research on exposures and ailments and have posted a significant amount of information and guidance on their website: https://www.cdc.gov/biomonitoring/PFAS_FactSheet.html.
PFAS exposure can have both short and long-term effects on the human body. Exposure to AFFF and PFAS can cause short-term effects such as:
- irritation of the skin, throat, nose and eye and mucous membranes,
- and drowsiness.
Research also ties leukemia, lymphoma, and neuroendocrine tumors to prolonged exposure to some PFAS.
Firefighters are shown to have disproportionately high rates of cancer in comparison to the public. Additional data is being collected through the FEMA-funded Firefighter Cancer Cohort Study to provide an epidemiological survey of PFAS exposure and cancer. Below are several general precautions firefighters and first responders should consider during and following use of products suspected of containing PFAS:
- Personnel should use self-contained breathing apparatus of positive pressure-supplied air respirators during handling, mixing, application or immediate clean-up of AFFF.
- Skin should be covered with proper water-resistant clothing and gloves to avoid dermal contact with AFFF.
- During standard fire operations, firefighters should wear turnout gear per specific department requirements.
- First responders should follow best hygiene practices to reduce PFAS exposure.
- Firefighters should wash hands and other exposed skin after using AFFF reduce irritation.
- Firefighters should also wash hands prior to eating or smoking to prevent accidental ingestion of PFAS.
Now here is the other edge of the sword:
“The International Association of Fire Fighters (IAFF) and Metropolitan Fire Chiefs Association (Metro Chiefs) have come together to notify members of the adverse health risks from fire fighter turnout gear. Recent studies have shown that all three layers of fire fighter turnout gear contain Per and Polyfluoroalkyl Substances (PFAS), a class of fluorinated chemicals known as “forever chemicals” which have been linked to cancer and other serious health effects. These studies highlight the risks associated with the materials and finishes used in turnout gear even before it is exposed to its first fire. Identifying safe and effective PFAS-free materials for turnout gear is a long and challenging process. Until PFAS is fully removed from turnout gear, the IAFF and Metro Chiefs are asking fire fighters to reduce exposure to PFAS in turnout gear by using the following precautions:
- Turnout gear should NOT be taken into firehouse living areas.
- When transporting gear in personal vehicles, it should be in a sealed container or bag, and preferably NOT transported in the passenger compartment.
- Apparatus cabs should be cleaned regularly and after every fire.
- Wash your hands after handling turnout gear.
- Legacy turnout gear should be replaced as new PFAS-free technologies become available.
- Do not wear turnout gear on responses where this level of protection is not necessary.”
In other words, as soon as your bunker gear is no longer necessary for firefighting or related emergency operations, it should be removed. No longer is it appropriate or recommended for firefighters and other responders to wear their gear after the fire, slogging around the scene, taking a breather and hanging out with their buddies until time to head back to the station.
This recommendation while timely and well-regarded places the responsibility of fire departments across the nation to develop, implement and enforce a new set of directives that reflect this new caution.
PPE CLEANING AND DECONTAMINATION
Taking another step to further protect the responder and their loved ones: Turnout gear should not be washed in home washing machines, but should be cleaned in a dedicated washing machine to avoid contaminating other clothes.
So, if your department doesn’t have an appropriate process (read that commercial/industrial grade washing system with specific wastewater catch/filtering system or a contract with a certified PPE cleaning contractor) it is strongly advisable to do so without delay.
PPE has an expected lifecycle for use. At the end of life, PPE should be discarded due to damage or excessive use in accordance with local, State and federal regulation.
THIS JUST IN
Many of you may have heard about microplastics and the suspected impact on our health. Well, as a bearer of bad news…”A new study finds how nanoplastics journey up the food chain, from being absorbed from the soil … moving to insects, and eventually winding up in fish. The authors note this could pose potential health risks if this process is replicated with crops and organisms. Recent studies have found microplastics in human lungs and blood, and nanoplastics have even been found in the remote North and South Poles of the Earth. To further relay distressing news, studies show that microplastics are often made of or contain PFAS further threatening the health and well-being of humans. A study has found that micro and nano plastics that are inhaled can increase by 10X the lethality in humans. And finally, the results of an Israeli study published by Environmental International has found microplastics in 80% of the subjects blood it tested.
Unfortunately, PFAS-containing products and equipment will remain in the firefighting and first response universe for many years to come. Whether it’s due to budget constraints, lack of inertia, overwhelming “other” priorities or lack of understanding, it is critical that those who defend our communities continue pressuring their legislators and decision-makers to commit to the rapid replacement of all PFAS-containing tools, products, PPE and equipment to ensure a safer, healthier environment.
- I trust my attempt at levity was taken simply as that. I served one year as a ladder driver operator and profess my undying admiration and respect for those who work above the oven.
- Cook and E. Steinle-Darling
- Linstrom et al. and Bech et al.
SEVEN SIMPLE CANCER PREVENTION HABITS
Habit 1. Advocate for yourself.
Habit 2. Always wear appropriate PPE including your SCBA.
Habit 3. Always wash hands and contaminated areas after each medical call.
Habit 4. Don’t use contaminated hoods.
Habit 5. Gross decon immediately following the event.
Habit 6. Take a shower within an hour of exposure and shower before leaving the station.
Habit 7. Decon apparatus and equipment.
*Recently commercial startups are reporting the possibility of treating AFFF products to reduce their harmful properties.