Use of Aqueous Film-Forming Foams and Knowledge of Perfluorinated Compounds Among Florida Firefighters

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To the Editor: The US Navy developed aqueous film-forming foam (AFFF) in the 1960s containing per- and polyfluoroalkyl subsances (PFAS) and synthetic foaming surfactants that allowed for improved firefighter safety, particularly for firefighters involved in liquid fuel and crash fire rescue operations and those using nozzles during structural firefighting.1 PFAS are also commonly used to water and stain-proof specific textiles such as the materials used to construct firefighter turnout gear.2,3 AFFFs have evolved to include a number of different formulations (including AFFFs that meet Military Specifications [MILSPEC], alcohol-resistant aqueous film-forming foam [AR-AFFF], etc.) that often, but not always, rely on PFAS compounds for proper foam performance. AFFFs used to fight class B petroleum fires have historically contained longer chain PFAS such as perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS)4–6 that are associated with adverse health outcomes.7,8 PFOS use in new AFFFs and other products were banned in the European Union in 2011 and Canada in 2013, and major US manufacturers of AFFF indicated they would no longer produce PFOA-based fluorosurfactant foams after 2015.9,10 However, AFFFs typically have a long shelf life of up to 25 years.11 In addition, current fluorinated AFFFs contain shorter chain PFAS chemicals with less information on potential toxicity. Little is known about AFFF use and knowledge of legacy and current PFOA and PFOS chemicals among firefighters. Some PFAS are associated with cancer, such that in 2016 the International Agency for Research on Cancer (IARC) classified PFOA as Group 2B indicating they are possibly carcinogenic to humans, based on limited evidence in humans that it can cause testicular and kidney cancer, and limited evidence in laboratory animals.7,12,13 Since the IARC designation, some additional cancer studies have suggested an increased risk of testicular cancer with increased PFOA exposure, whereas others have suggested possible links to thyroid cancer and kidney cancer.14–16 Epidemiologic studies have associated firefighting with an increased risk for a variety of cancers, including testicular and kidney cancer, among others, but the exposures responsible for these increased rates have not been identified.17,18 To date there is limited knowledge about the use of PFOA/PFOS containing foams within the US fire service. This is of greater concern in airport facilities where AFFFs that meet the MILSPEC are required for use on Federal Aviation Administration (FAA)-regulated airports and military airports. Concerns about AFFF use and PFOA/PFOS chemical exposure center around the potential negative impact on firefighter health as well as on the environment from the discharge of foam solutions generated from the combination of water and foam concentrate. When PFOA/PFOS-containing AFFF are repeatedly used in one location over an extended period of time (such as in firefighter training facilities), the PFOA/PFOS can move from the foam substance into soil and then into groundwater.19–21 The amount of PFOA/PFOS that enter the groundwater depends on the type and amount of AFFF used, where it was used, and the type of soil and other factors. At firefighter training facilities, where AFFF is often repeated discharged onto concrete training areas, long-term release of PFAS into the surrounding soil and water from the concrete is anticipated to occur on the order of decades.22 As an initial first step to study the concern about AFFF use and PFOA/PFOS knowledge, we assess the awareness and knowledge of perfluorinated chemicals and AFFF use among Florida fire departments. MATERIALS AND METHODS Study Design and Participant Recruitment A cross-sectional study design was used to collect health and safety survey information from 142 firefighters attending the Florida Fire Chiefs’ Association Health and Safety Conference held on December 10 to 12, 2018, in Orlando, FL. Our research team distributed paper surveys during the conference initially by placing a blank survey at each seat in the main conference ballroom, and through distribution at a dedicated exhibitor table located in the immediate entry/egress of the main conference meeting room. The annual Florida fire chiefs meeting is open to all Florida firefighters and is largely composed of attendees from senior-level positions within Florida fire services, including fire chiefs, assistant chiefs, fire prevention officers, shift officers, individual firefighters/paramedics, health and safety officers, and fire investigators. To encourage completion of the survey, conference organizers made an announcement to attendees on the main conference stage twice a day. A t-shirt with the research team's Firefighter Cancer Initiative logo was provided to each firefighter that completed the survey. A verbal consent process was used given the anonymous nature of the survey, where the first page of the survey contained the consent information; firefighters were provided a copy upon request. A total of 11 surveys were removed from the final analytic dataset used in this study given three surveys were from firefighters outside the State of Florida and eight survey respondents indicated they did not know if their department used AFFF, the main study outcome variable. Survey Instrument and Study Measures We designed a 97-item survey instrument, Firefighter Assessment of Strategies Trumping Cancer (FAST-C), with the goal of documenting fire department and individual firefighter-level decontamination practices among Florida firefighters. Survey measures were adapted from previously validated or administered surveys of occupational safety and health and worksite health promotion.23–25 New measures assessing awareness and knowledge of PFOA/PFOS and AFFF use were adapted from other occupational health and safety measures26,27 and assessed for content and face validity with Florida fighters before survey administration. AFFFs Use and Knowledge Measures We asked survey respondents “Does your fire service department use AFFFs?” with response options “Yes, No, or Don’t Know.” We assessed the frequency of AFFF use with the question “Approximately how many times each year does your fire department answer calls in which you need to use AFFFs?” with response options “0 to 1, 2 to 5, 6 to 10, 11 to 15, 16 to 20, 20+, or Don’t Know.” Measures assessing AFFF brand, formulation, PFOA/PFOS components, and decontamination post-AFFF fire suppression use were assessed with the following questions all with “Yes, No, or Don’t Know” response options: “Do you know the brand or manufacturer of the AFFF that your fire department currently uses?”; “If your department uses/stores AFFF, are you aware if it is the original formulation or the newest formulation?”; “Do you know if the AFFF, which you currently use, has PFOA or PFOS as a main component?”; and “After incidents where AFFFs are employed, do you and others in your fire department exchange or wash your gear?.” Lastly, we assessed the firefighter's interest in the following current trade profession discussion on AFFF and PFOA on turnout gear with the two questions: “Do you follow the current discussion about AFFF” and “Do you follow the current discussion about PFOA and turnout gear?” with response options “Yes, No, or Don’t Know.” Organizational Characteristics We evaluated four organizational characteristics of the fire department: workforce size, total health and safety officers, fire department geographic location, and employment type. Workforce size was defined as the number of active firefighters (nonadministrative positio

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