1. TM 1 Is Heart Disease in the Fire Service a Concern? Thomas Hales, MD, MPH CDC – NIOSH DHS - Program/Office of Grants and Training Meeting January 8, 2007 WDC

2. TM 2

3. 3 Outline Heart disease and fire fighting Key findings Key Recommendations Research Needs TM

4. Exposures CO Shiftwork & Overtime Heat & Noise Diesel exhaust & ETS Rapid HR & ↑ BP: – emergency calls – heavy physical exertion Source: Steenland & Fine. Occup Med State of the Art Reviews 2000;15:7-24

5. 5 Heavy physical exertion Trigger Heart attacks Sources Willich et. al. NEJM 1993;329:1684 Tofler et. al. J Am Coll Cardiol 1992;20:1049 Mittleman et. al. NEJM 1993;329:1677

6. 6 Exposures Heavy physical exertion Trigger ?? Heart attacks TM

7. 7 CVD Fatalities by Location N=134

8. 8 Risk Factors for On-duty CVD Fatalities Risk FactorOR(95% CI) Fire Suppression64(7.4-556) Training7.6(1.8-31.3) Alarm Response5.6(1.1-28.8) Source: Kales et. al. Environ Hlth: a global access science source. 2003;2:14

9. 9 Findings - CVD Fatalities by Time of the Event TM

10. 10 Circadian Distribution of CHD Kales et. al. Environ Hlth: a global access science source. 2003;2:14

11. 11 Do FF have increased RATES of heart disease? 25 SMR studies – mixed results Limitation - Healthy Worker Effect In 2000, Choi concludes, “there is strong evidence of an increased risk of death overall from heart disease among fire fighters.” Source: Choi. J Occup & Environ Med 2000;42:1021-34. TM

12. 12 Do FF have increased RATES of heart disease? In 1995, Guidotti concluded, “sudden death, myocardial infarction, or fatal arrhythmia occurring on or soon after near-maximal stress on the job are likely to be [work] related….” Source: Guidotti. J Occup & Environ Med 1995;37;1348-56 TM

13. 13 Acute Exposures Heavy physical exertion Trigger Heart attacks ?? TM

14. 14 Outline Heart disease and fire fighting Key findings Key Recommendations Research Needs TM

15. 15 Findings - Autopsy Only 69% of CVD fatalities had autopsies performed Why? –Cause of Death –PSOB application TM

16. 16 Findings: CAD Risk Factors 90% ≥ 1 CAD risk factors Modifiable –Diabetes, Hypertension, Smoking, Cholesterol, Obesity/Lack Exercise Non-Modifiable –Age, Gender, Family Hx

17. 17 Findings: CAD Risk Factors 90% ≥ 1 CAD risk factors – High cholesterol (58%) – Smoking (57%) – HTN (49%) – Lack of exercise/obesity (42%) – Diabetes (16%)

18. 18 Pre-placement Medical Evaluations 134 101 (77%) 86 Careers (100%) 15 Volunteers (31%) Pre-placement Medical Evaluations Illness Investigations TM

19. 19 Periodic Medical Evaluations 134 77 (57%) 71 Careers (83%) 14 Volunteers (29%) Periodic Med Evaluations Illness Investigations TM

20. 20 Periodic Medical Evaluations 134 28 (21%) 28 Careers (33%) 0 Volunteers (0%) Exercise Stress Tests Illness Investigations TM

21. 21 Wellness/Fitness Programs, 1998-2004 134 Wellness (39%) Fitness (49%) Voluntary (40%) Mandatory (9%) Illness Investigations TM

22. 22 CVD Fatalities – Resuscitation Automated External Defibrillators (AEDs) –Misuse in 4 cases TM

23. 23 Findings - Surprising CO poisoning –possible factor in only few CVD fatalities Cardiomyopathy cases –Particularly among young FF No fatalities due to hypoglycemia due to diabetes –Lack of FF with diabetes?

24. 24 Outline Heart disease and fire fighting Key findings Key Recommendations Research Needs TM

25. 25 Recommendations Autopsies Medical Screening Programs –EST Fitness/Wellness Programs –Phased-in, non-punitive –Negotiated with local union Resuscitation training –AEDs & intubation procedures

26. 26 Outline Heart disease and fire fighting Key findings Key Recommendations Research Needs TM

27. 27 Research Needs – Workplace factors Health effect of chronic CO exposure Exposure to cyanide (HCN) –Environmental –Biological monitoring TM

28. 28 Research Needs – Personal Risk Factors Barriers to implementing wellness/fitness programs –Effectiveness studies –Cost-effectiveness studies TM

29. 29 TM The findings and conclusions in this presentation have not been formally disseminated by the National Institute for Occupational Safety and Health and should not be construed to represent any agency determination or policy.