This is the first study to describe real world on-scene exposure decontamination practices by fire personnel using data entered into a fire incident management system, with records from over 2,500 firefighters throughout the United States. Our results suggest that too few fire personnel are performing decontamination on-scene following documented exposure.
Keywords: on-scene decontamination, firefighter, decontamination procedure, decontamination documentation, fire exposure, fire decontamination, occupational exposure
Abstract
Objective
This study describes firefighters’ on-scene decontamination procedure use post–working fire and frequency of adherence to best practice.
Methods
This retrospective analysis of working fires was conducted using records from the ESO Data Collaborative (Austin, TX) national research database from January 1, 2021, to December 31, 2021. Documentation of decontamination procedures was examined among records with smoke or combustion products exposure. Firefighter and incident characteristics were evaluated. Descriptive statistics and univariable odds ratios were calculated.
Results
Among the 31,281 firefighters included in the study, 8.0% documented a fire-related exposure. Of those, 82% performed at least one on-scene decontamination procedure; 5% documented all decontamination procedures defined as best practices. The odds of documenting any decontamination procedure were significantly decreased among firefighters responding to incidents in rural areas compared with urban areas (odds ratio, 0.70).
Conclusions
Fire personnel may not be taking all necessary decontamination steps post–working fires.
LEARNING OUTCOMES
Discuss the importance of on-scene decontamination practices after fire personnel exposures during a working fire.
Identify best practices for fire personnel decontamination and discuss adherence to these guidelines.
Summarize the relationship between fire personnel demographics, fire incident characteristics, and on-scene decontamination practices.
Fire personnel are at risk for exposure to known or suspected carcinogens during firefighting activity.1,2 Occupational exposures, including but not limited to smoke and other products of combustion, among fire personnel increase the risk of cancer diagnoses and death compared with the general population.3–5 A dose-response relationship has been identified between exposures faced during firefighting activities and cancer-related mortality.6 Incidence of cancer increases with increased time spent at fire scenes and number of fires worked.6 Furthermore, fire personnel may continue to be exposed to products of combustion due to off-gassing after firefighting activities leading to contamination on skin and/or personal protective equipment (PPE) if appropriate decontamination procedures are not performed.7 Indeed, it follows that a multiyear study funded by the National Institute for Occupational Safety and Health found that cancer is the leading cause of line-of-duty firefighter deaths.6
Field decontamination of skin and PPE is an integral and effective step in protecting fire personnel’s health and safety.4 Gross decontamination with wet soap has been shown to reduce carcinogenic exposures by a median of 85% while cleansing wipes used on the skin of the neck reduced exposures by a median of 54%.7 Decontamination processes studied in laboratory settings have even been shown to effectively disinfect firefighter suits after exposure to biological contaminants.8 Specifically, detergents showed greater than 90% decontamination effectiveness on the chest and thighs of firefighter suites.8 Furthermore, ethanol showed greater than 60% decontamination effectiveness on same area of firefighter suites.8 While detergents were more effective than alcohol, neither decontamination fluid completely removed pathogens from evaluated areas of the firefighter suit.8
Because of the effectiveness of decontamination at decreasing fire personnel exposure risk, the recent update to the Lavender Ribbon Report for Preventing Firefighter Cancer was released by the International Association of Fire Chiefs and the National Volunteer Fire Council. 9 This report outlines 11 best practices for preventing cancer in fire personnel including the following:
Full personal PPE must be worn throughout the entire incident, including a self-contained breathing apparatus during salvage and overhaul.
A second hood should be provided to all entry-certified personnel in the department.
After exit from the immediately dangerous to life or health and while still on air, immediate gross decontamination of PPE using soapy water and a brush, if weather conditions allow, should be performed. Personal protective equipment should then be placed into a sealed plastic bag and placed in an exterior compartment of the rig, or if responding in personally owned vehicle, placed in a large storage tote, thus keeping the off-gassing PPE away from self and passengers.
Exposed areas of the body (neck, face, arms, and hands) should be wiped off immediately using wipes. Remove as much soot as possible from the head, neck, jaw, throat, underarms, and hands immediately.
Change clothes and wash them after exposure to products of combustion or other contaminants. Do this as soon as possible or isolate in a trash bag until washing is available.
Shower as soon as possible after being exposed to products of combustion or other contaminants. “Shower within the hour.”
Personal protective equipment, especially turnout pants, must be prohibited in areas outside the apparatus floor (ie, kitchen, sleeping areas, etc) and never in the member’s household.
Wipes, or soap and water, should also be used to decontaminate and clean apparatus seats, self-contained breathing apparatus, and interior crew area regularly, especially after incidents where personnel were exposed to products of combustion.
All firefighters should get an annual physical, as early detection is the key to survival.
Tobacco products of any variety, including dip and e-cigarettes, should never be used on or off duty.
Fully document all fire or chemical exposures on incident reports and personal exposure reports.
Two of the 11 best practices describe decontamination procedures that should be performed immediately on the fireground scene after the individual has left areas that are immediately dangerous to life or health. These on-scene decontamination procedures can be captured on fire incident reporting systems. Data collected from these systems can provide insight into real-world decontamination practices patterns and their alignment with published best practices.
Large-scale, national evaluations of fire personnel post–working fire on-scene decontamination practices are scant. However, a survey of 500 firefighters found positive attitudes toward post–fire decontamination; however, cleaning and decontamination after each fire were not performed regularly and consistently.9 Understanding the current practice patterns for post–working fire decontamination can guide future interventions to further protect firefighter health and safety. The objectives of this study were to use a large, national dataset of fire incident reporting system records to describe fire personnel decontamination practices and factors related to decontamination procedure performance. Second, this study sought to identify the frequency of adherence to on-scene best practices for firefighter decontamination and evaluate factors associated with the performance of post–working fire on-scene decontamination procedures.
METHODS
Study Design and Setting
This was a retrospective analysis of fire records from the ESO Data Collaborative (Austin, TX) national research database. ESO is a large provider of fire records management system (RMS) software (Austin, Texas, USA) that facilitates collection of comprehensive fire scene information including data related to incidents, inspections, scheduling, activities, and personnel management. The ESO Fire RMS meets the National Fire Incident Reporting System standard. The ESO Data Collaborative consists of participating agencies who permit research using their deidentified records. The data were entered by fire personnel as part of their typical record keeping activities. In 2021, the ESO Data Collaborative consisted of more than 600 participating fire agencies from the United States and represented more than 3 million incidents.
The study period was from January 1, 2021, to December 31, 2021. All records for working fires, recorded as “111” incident type, with exposure to smoke or products of combustion were included. Records were excluded from the analysis if no fire personnel were listed on the incident. The institutional review board at St David’s HealthCare determined that this study was exempt (22-04-04X). The study methods were compliant with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist for cohort studies (Fig. 1, Supplemental Digital Content, http://links.lww.com/JOM/B384).
FIGURE 1.
Inclusion for analysis.
Outcomes
The primary outcome of the study was documentation of any on-scene decontamination procedures among those with a documented exposure. The secondary outcome of interest was documentation of best practices for on-scene post–working fire decontamination among those who documented any on-scene decontamination procedures. Best practices were defined as documentation of all of the following in the multiselect “Decontamination Procedures Completed” data field within the ESO Fire RMS: wet brush gear with soap, used wet wipes on any area, cleaned neck, face, arms, and exposed areas using wet wipes, as well as gear bagged, placed outside of cab. Use of wet wipes entails fire personnel removing gross contaminants with commercial wipes designed to dissolve dirt, oil, soot, and other hydrocarbons. A commonly used brand of wipes in the United States are formulated with Micellar Water. The size of commercial wipes can range from 8 × 8 to 12 ×24 inches.10
Measures
All on-scene decontamination procedures evaluated included dry brush gear, wet brush gear with soap, wet brush gear without soap, use of wet wipes on any area, cleaning of neck, face, arms, and exposed areas using wet wipes, gear bagged and placed in cab, and gear bagged and placed outside cab. Fire personnel demographics obtained from the ESO (Austin, Texas, USA) Personnel Management System including age, sex (male/female), race/ethnicity (White, not Hispanic/Latino[a]; Black, not Hispanic/Latino[a]; other, not Hispanic/Latino[a]; Hispanic/Latino[a]), work status (full-time paid, full-time unpaid, part-time paid and part-time unpaid, part-time paid, part-time unpaid), fire personnel rank (chief, officer, engineer, firefighter, prevention, other), and fire personnel tenure (<1 year, 1–4 years, 5–9 years, 10–14 years, 15–19 years, ≥20 years) were also evaluated. Incident characteristics were also evaluated including incident location community size (urban/rural) and incident time of day (day, evening, night).
Data Analysis
Records that did not have any on-scene post–working fire decontamination documented were compared with those that documented any type of on-scene post–working fire decontamination procedures in the “Decontamination Procedures Completed” data field. Descriptive statistics were calculated. Continuous variables were presented as medians and interquartile ranges (IQRs) and categorical variables were presented as counts and percentages. Univariable logistic regression was performed to describe the odds of documentation of any decontamination procedures by fire personnel demographics and incident characteristics. All analyses were performed using Stata v16.1 (College Station, TX).
RESULTS
In 2021, there were 15,538 records for building fires with exposure to smoke or products of combustion from 655 agencies. A total of 5,264 records (33.8%) were excluded from the analysis because no fire personnel were listed on the incident record. There were 31,281 fire personnel from 581 agencies among the remaining 10,274 incidents (Fig. 1). The majority of these fire personnel had their sex documented as male (94%) and race/ethnicity documented as White, not Hispanic/Latino(a) (92%). The median age was 39 years (IQR, 32–48 years). More than three quarters (85%) were listed as full-time paid and median tenure was 9 years (IQR, 3–18 years). The most frequently documented rank was firefighter (51%), followed by officer (23%), and chief (9%). Fire personnel most often responded to incidents that occurred during the day (43%) and in urban areas (86%). There were 2,509 (8.0%) that documented any exposure related to the fire incident (Table 1).
TABLE 1.
Firefighter Characteristics and Incident Characteristics
| N = 31,281 | n | % | Missing |
|---|---|---|---|
| Sex | |||
| Male | 18,807 | 94.2% | 11,327 |
| Female | 1147 | 5.8% | |
| Race | |||
| White, not Hispanic/Latino(a) | 10,335 | 91.7% | 20,016 |
| Black, not Hispanic/Latino(a) | 368 | 3.3% | |
| Other, not Hispanic/Latino(a) | 99 | 0.9% | |
| Hispanic/Latino(a) | 463 | 4.1% | |
| Age, y | |||
| Median (IQR) | 39 (32–48) | 12,482 | |
| Work status | |||
| Full-time paid | 8113 | 84.7% | 21,704 |
| Full-time unpaid | 51 | 0.5% | |
| Part-time paid and part time unpaid | 125 | 1.3% | |
| Part-time paid | 898 | 9.4% | |
| Part-time unpaid | 390 | 4.1% | |
| Firefighter rank | |||
| Chief | 889 | 9.0% | 21,374 |
| Officer | 2314 | 23.4% | |
| Engineer | 977 | 9.9% | |
| Firefighter | 5045 | 50.9% | |
| Prevention | 55 | 0.5% | |
| Other | 627 | 6.3% | |
| Firefighter tenure, y | |||
| Median (IQR) | 8.6 (3.3–17.9) | 21,726 | |
| Tenure categories | |||
| <1 y | 687 | 7.2% | 21,726 |
| 1–4 y | 2696 | 28.2% | |
| 5–9 y | 1766 | 18.5% | |
| 10–14 y | 1234 | 12.9% | |
| 15–19 y | 1273 | 13.3% | |
| ≥20 y | 1899 | 19.9% | |
| Time of day | |||
| Day (9:00–17:59) | 13,482 | 43.1% | 0 |
| Evening (18:00–23:59) | 8612 | 27.5% | |
| Night (0:00–08:59) | 9187 | 29.4% | |
| Incident location community size | |||
| Urban | 26,745 | 85.5% | 9 |
| Rural | 4527 | 14.5% | |
| Documented exposure | |||
| Yes | 2509 | 8.0% | 0 |
| No | 28,772 | 92.0% | |
Among fire personnel with a documented smoke or combustion product exposure, 2047 (82%) performed at least one on-scene decontamination procedure. The most common decontamination procedure reported was cleaning of the neck, face, arms, and exposed areas with wet wipes (n = 1624, 65%). Gear bagged and placed in cab was the least common decontamination procedure reported (n = 212, 8%) (Fig. 2). Documentation of any decontamination procedures was similar across fire personnel demographics (Table 2). When responding to incidents in urban areas, fire personnel documented performance of decontamination more often than when responding in rural areas (urban: n = 1711, 83% vs. rural: n = 335, 77%). There were 103 (4%) of the 2,509 with documented exposure that documented all on-scene decontamination procedures defined as best practices (Fig. 1).
FIGURE 2.
Decontamination procedures performed among those who Documented any On-Scene Decontamination*.
TABLE 2.
Documented Decontamination Procedures
| All Decontamination Best Practices Documented | No Decontamination Procedures Documented | Any Decontamination Procedure Documented | |
|---|---|---|---|
| Sex | |||
| Male | 58 (3.5%) | 316 (19.2%) | 1327 (80.8%) |
| Female | 3 (3.4%) | 15 (17.1%) | 73 (82.9%) |
| Race | |||
| White, not Hispanic/Latino(a) | 29 (2.8%) | 208 (20.4%) | 814 (79.6%) |
| Black, not Hispanic/Latino(a) | 3 (7.1%) | 6 (14.3%) | 36 (85.7%) |
| Other, not Hispanic/Latino(a) | 0 (0.0%) | 0 (0.0%) | 6 (100.0%) |
| Hispanic/Latino(a) | 2 (4.1%) | 14 (28.6%) | 35 (71.4%) |
| Age, y | |||
| Median (IQR) | 35 (29–45) | 37 (30–45) | 37 (31–46) |
| Work status | |||
| Full-time paid | 47 (6.1%) | 174 (22.6%) | 595 (77.4%) |
| Full-time unpaid | 0 (0.0%) | 0 (0.0%) | 2 (100.0%) |
| Part-time paid and part time unpaid | 1 (10.0%) | 1 (10.0%) | 9 (90.0%) |
| Part-time paid | 0 (0.0%) | 27 (28.7%) | 67 (7.3%) |
| Part-time unpaid | 0 (0.0%) | 2 (18.2%) | 9 (81.8%) |
| Firefighter rank | |||
| Chief | 3 (5.5%) | 14 (25.4%) | 41 (74.5%) |
| Officer | 10 (4.4%) | 49 (21.3%) | 181 (78.7%) |
| Engineer | 6 (6.7%) | 19 (21.4%) | 70 (78.6%) |
| Firefighter | 15 (3.2%) | 124 (26.6%) | 342 (73.4%) |
| Prevention/other | 1 (2.5%) | 8 (20.0%) | 32 (80.0%) |
| Firefighter tenure, y | |||
| Median (IQR) | 8.9 (5.2–16.8) | 7.8 (3.0–15.6) | 8.2 (2.7–16.2) |
| Tenure categories | |||
| <1 y | 2 (2.2%) | 20 (21.5%) | 73 (78.5%) |
| 1–4 y | 10 (4.2%) | 47 (19.8%) | 190 (80.2%) |
| 5–9 y | 16 (9.1%) | 48 (27.3%) | 128 (72.7%) |
| 10–14 y | 4 (3.3%) | 32 (26.7%) | 88 (73.3% |
| 15–19 y | 8 (6.6%) | 23 (19.0%) | 98 (81.0%) |
| ≥20 y | 8 (5.8%) | 33 (23.9%) | 105 (76.1%) |
| Incident location community size | |||
| Urban | 94 (4.5%) | 361 (17.4%) | 1711 (82.6%) |
| Rural | 9 (2.1%) | 101 (23.2%) | 335 (76.8%) |
| Time of day | |||
| Day (9:00–17:59) | 38 (3.7%) | 181 (17.6%) | 846 (82.4%) |
| Evening (18:00–23:59) | 15 (2.3%) | 132 (20.2%) | 522 (79.8%) |
| Night (0:00–08:59) | 50 (6.0%) | 149 (18.0%) | 679 (82.0%) |
Data are presented as n (%).
When compared with responses in urban areas, the odds of documenting any decontamination procedure were significantly decreased when responding to incidents in rural areas (odds ratio, 0.70; 95% confidence interval, 0.55–0.90). There was no statistically significant difference found with respect to the documentation of any decontamination procedure among any other fire personnel demographics or incident characteristics (Table 3).
TABLE 3.
Univariable ORs for Any Decontamination Procedures
| OR | 95% CI | |
|---|---|---|
| Sex | ||
| Male | Referent | Referent |
| Female | 1.15 | 0.66–2.04 |
| Race | ||
| White, not Hispanic/Latino(a) | Referent | Referent |
| Minority | 0.98 | 0.59–1.65 |
| Age, y | ||
| Median (IQR) | 1.00 | 0.99–1.01 |
| Work status | ||
| Full-time paid | Referent | Referent |
| Other | 0.85 | 0.54–1.33 |
| Firefighter rank | ||
| Chief | Referent | Referent |
| Officer | 1.26 | 0.64–2.50 |
| Engineer | 1.25 | 0.57–2.78 |
| Firefighter | 0.94 | 0.50–1.79 |
| Prevention/other | 1.37 | 0.51–3.65 |
| Firefighter tenure, y | ||
| Median (IQR) | 0.99 | 0.97–1.01 |
| Tenure categories | ||
| <1 y | 1.15 | 0.61–2.16 |
| 1–4 y | 1.27 | 0.77–2.11 |
| 5–9 y | 0.84 | 0.50–1.40 |
| 10–14 y | 0.86 | 0.49–1.52 |
| 15–19 y | 1.34 | 0.74–2.43 |
| ≥20 y | Referent | Referent |
| Time of day | ||
| Day (9:00–17:59) | Referent | Referent |
| Evening (18:00–23:59) | 0.85 | 0.66–1.08 |
| Night (0:00–08:59) | 0.97 | 0.77–1.24 |
| Incident location community size | ||
| Urban | Referent | Referent |
| Rural | 0.70 | 0.55–0.90 |
CI, confidence interval; OR, odds ratio.
DISCUSSION
This study describes real-world on-scene exposure decontamination practices of more than 2000 fire personnel throughout the United States. Our results suggest that too few are performing and/or documenting decontamination on-scene after documented exposure, with almost 1 in 5 exposed fire personnel having no decontamination procedures documented. Adherence to all best practices for on-scene post–working fire decontamination was documented for less than 5% of exposed fire personnel in this study. This study supports the findings from Harrison et al11 indicating inconsistent decontamination after each fire.
When fire personnel responded to incidents in rural areas, they were significantly less likely to document performance of any on-scene decontamination procedures, with almost one quarter having no documentation of on-scene decontamination procedures after post–fire exposure. These results are similar to those of a survey of firefighters, which found that only 19% of respondents indicated that their gear was cleaned after each use.12 While the Lavender Report describes the cost benefits of appropriate prevention including on-scene decontamination, a majority of firefighters in rural areas described cost as a barrier to cleaning gear regularly.9,12 Barriers to complete decontamination steps are not captured in the record. Further research is needed to identify factors in rural areas limiting their performance of decontamination procedures.
It should be noted that almost one in 10 fire personnel in this study documented placing their bagged gear in the cab after exposure during a fire incident. This practice puts them at risk for additional exposure.7 This practice is also specifically identified as a practice that should be avoided by the Lavender Report update. 9 However, prior research has identified suboptimal perceptions of risk and practices for the storage of turnout gear.12 Further research is needed to identify factors that support cancer prevention activities among firefighters.
Complete documentation is emphasized in the most recent Lavender Report update.9 While it is possible that incomplete documentation practices are masking greater performance of decontamination procedures, prior research suggests that fire personnel behavior as it relates to decontamination is not aligned with recommendations.11,12 Nevertheless, leadership in the fire service should continue to emphasize the need for complete and accurate documentation of exposures and decontamination procedures. Furthermore, studies have found that despite high awareness and perception of occupational cancer risk among firefighters, the most reliable predictors of hazard adjustment behaviors such as on-scene decontamination are peer perception, self-efficacy, and a strong cultural norm of safety.13 Strategies to support safety in the fire service should be investigated in future research.
Limitations
This was a large retrospective evaluation of fire records, which were obtained from a convenience sample of fire agencies who voluntarily contributed deidentified data for research. Thus, these data were originally recorded for the purposes of documentation of fire suppression and related activities and not as part of a study. This analysis includes data from 581 agencies, representing a small subset of the registered fire departments across the United States. These limitations may impact the generalizability of the study findings. Furthermore, as noted previously, it is possible that decontamination procedures were performed but not documented in the RMS; however, previous surveys of firefighter decontamination practices suggest that insufficient documentation, alone, is not the only driver for our study results.11,12
This study was only able to evaluate best practices that were performed on-scene. It is possible that fire personnel are more likely to complete other best practices once back at the fire station. However, these activities, such as showering within an hour, would not be captured in a fire RMS and are unlikely to be documented. Methods to facilitate documentation of all best practices for firefighter cancer prevention should be investigated.
There was a notable amount of missing data for fire personnel demographics. While it is required that information related to the fire incident is documented (such as time of day and incident location), fire personnel demographics are not required data fields. This limited our ability to evaluate the relationship between demographic factors and decontamination performance practices. Strategies to support documentation of demographics in personnel management systems are needed.
CONCLUSIONS
Fire personnel may not be taking all necessary, and recommended, steps to reduce carcinogenic exposures after a working fire. On-scene post–fire decontamination procedures were underused in this study. Almost one in five fire personnel with a documented exposure did not document performance of any decontamination procedures on-scene after a fire incident. Furthermore, documentation of best practices for on-scene decontamination was rare, with less than 5% of exposed fire personnel in this study documenting all on-scene decontamination best practices outlined by the International Association of Fire Chiefs and the National Volunteer Fire Council.
Fire personnel in rural areas may be at even greater risk when compared with those in urban areas. The lack of on-scene decontamination procedure performance documentation was even more pronounced in rural areas. When responding to incidents in rural areas fire personnel had significantly reduced odds of performing any decontamination procedures when compared with fire responses in urban areas. Almost a quarter of fire personnel did not document any on-scene decontamination procedures after a working fire in a rural area.
Leadership in the fire service should continue to emphasize the need for complete and accurate documentation of exposures and decontamination procedures. Documentation of fire personnel demographics should be encouraged in personnel management systems.
Footnotes
Funding sources: None to disclose.
Conflict of interest: None declared.
Author contributions: All authors participated in study design, data analysis, and manuscript preparation.
Supplemental digital contents are available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.joem.org).
Contributor Information
Alison Treichel, Email: ali.treichel@eso.com.
J. Brent Myers, Email: brent.myers@eso.com.
Scott S. Bourn, Email: scott.bourn@eso.com.
Remle P. Crowe, Email: remle.crowe@eso.com.
Bill Gardner, Email: bill.gardner@eso.com.
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