On June 21, 2017, the Préventica Symposium for health and safety stakeholders was organized by the French National Syndicate of Firefighters and Administrative Personnel for Prevention in Paris, France, to study firefighter health and quality of life. This is their report.
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.
Key Words: Firefighters, Cancer; Firefighters, Carcinogens; Firefighters, Soot Exposure; Firefighters, Fire Smoke Cutaneous Exposure; Firefighters, Fire Smoke Dermal Exposure.
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.
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.  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)  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 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  such as aldehydes including acrolein, which is present in fire smoke.  Fire smoke can also contain polycyclic aromatic hydrocarbons (PAHs), which can induce these effects.  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). 
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|
|Benzo[a]pyrene (PAH)||Ethylbenzene||11 Different PAHs|
|Naphthalene (Volatile |
|Diesel Exhaust||Wood Dust||Silica Fibers|
|Asbestos||Tetrachloroethylene||Toluene Diisocyanate |
|Methylmercury and its Organic Salts|
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.  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. 
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.
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.  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|
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). 
Table 4. Recognition in Quebec Province, Canada of Certain Cancers Among Firefighters.
(Adapted from data of the CNESST , Articles 9.11 and 9.11.1)
|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:
- 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 .
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 .
France. Pourny  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.
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  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 . This has lead to individual and group 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)  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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