U.S. Fire Administrator’s Summit on Fire 

Prevention and Control

National Emergency Training Center

October 11, 2022
National Firefighter Registry: 

The Missing Piece

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Kenny Fent, PhD, CIH
WHAT DO WE KNOW?

U.S. Fire Administrator’s Summit on Fire Prevention and Control

https://www.iarc.who.int/infographics/iarc-monographs-evaluate-the-carcinogenicity-of-occupational-exposure-as-a-firefighter/
WHAT DON’T WE KNOW?

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 What is the cancer risk for volunteer firefighters?

 What is the cancer risk for the sub-specialties of the fire service?

 How does the cancer risk vary for demographic groups?

 How does the cancer risk vary regionally across the U.S. fire service?

 How prevalent are rare forms of cancer among firefighters?

 How does the cancer risk change with increasing exposures, 

including major events?

 What other occupational and non-occupational risk factors 

contribute to cancer risk among firefighters?

 To what extent do different control interventions and workplace 

practices reduce the risk of cancer?

 Are there other chronic illnesses that are elevated in firefighters?
NATIONAL FIREFIGHTER REGISTRY (NFR)

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Mission: To generate detailed knowledge about cancer in the fire service 

through a voluntary registry that reflects our nation’s diverse firefighters

Vision: To equip the fire service and public health communities with the 

knowledge they need to reduce cancer in firefighters

Goal: Enroll 200,000 firefighters

Specific aims:

1. Collect self-reported information on workplace & personal characteristics through web portal 

2. Obtain records from fire departments or agencies to track trends and patterns of exposure

3. Link with health information databases including population-based cancer registries and the 

National Death Index to detect cancers and deaths
THE MISSING PIECE

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Firefighter

Occupational 

exposures

Cancer

 Cancer is reportable in all 50 states

 Most states do not collect detailed information 

about occupation

 NFR allows you to register yourself as a firefighter

 NFR makes it possible to study the relationship 

between “firefighting” and “cancer”
U.S. Fire Administrator’s Summit on Fire Prevention and Control

ENROLLING IN THE NFR

 Visit web portal NFR.cdc.gov 

 Confirm eligibility and click Login.gov 

 Create account

 Read and sign consent form

 Fill out user profile

 Complete the questionnaire

 Demographics, work history, health 

history, lifestyle

30 – 45 minutes
DATA SECURITY

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Logging into web portal 

requires multi-factor 

authentication 

Email, password, and another 

form of authentication (e.g., 

text message passcode)

Data uploaded to an 

encrypted database 

each time the firefighter 

clicks “save and 

continue” or logs out

Logging out saves progress

Privacy protected by an 

Assurance of 

Confidentiality 

Identifiable information will 

not be shared outside of 

NIOSH
WHO’S ELIGIBLE?

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 ALL firefighters!

 Active and retired

 Career and volunteer

 Structural, wildland, or other specialties

 Those with or without cancer

 NIOSH will reach out to select fire departments to solicit 

participation and request incident records 

 Most will enroll through the open enrollment route (NFR.cdc.gov) 
WHAT HAPPENS AFTER ENROLLMENT?

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Matching to state cancer 

registries and data analyses

Data collection (including incident 

records and follow-up surveys)

Starting line

Enroll 

firefighters in 

NFR

Personal and 

demographic 

information

Demographic 

and regional 

differences in 

cancer risk

Work history 

and use of 

controls

Exposure-response 

relationships and 

impact of controls

Cancer risk by 

job category

Other occupational 

and nonoccupational factors

Quantification 

of cancer risk 

modifiers and 

confounders

200,000 or more!

Over next few years

Over next 10+ years
THANK YOU

U.S. Fire Administrator’s Summit on Fire Prevention and Control

The findings and conclusions in this presentation are those of the authors and do not 

necessarily represent the official position of the Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health. 
Kenny Fent, PhD, CIH

Lead, National Firefighter Registry (NFR) Program

National Institute for Occupational Safety and Health (NIOSH)

kif5@cdc.gov

U.S. Fire Administrator’s Summit on Fire Prevention and Control

CONTACT INFORMATION
U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire 

Prevention and Control

National Emergency Training Center

October 11, 2022
The Fire Fighter Cancer Cohort Study (FFCCS):

A Scientist-Fire Fighter Collaboration

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Jeff Burgess, MD, MS, MPH
FIRE FIGHTER CANCER COHORT STUDY (FFCCS)

U.S. Fire Administrator’s Summit on Fire Prevention and Control

FFCCS

Collect blood, urine, and 

other biological samples at 

enrollment, every two 

years, and as needed after 

exposures. Report back 

results to firefighters.

BIOLOGICAL SAMPLES

Collect exposure data from 

firefighters at the fireground, 

during training activities, and 

at other locations.

COLLECT EXPOSURE DATA

Integrate exposure, biological 

and health survey data 

through a centralized data 

center. Data protected by a 

Certificate of Confidentiality.

INTEGRATE DATA

Conduct basic and applied 

research through a communityengaged approach with the fire 

service to advance firefighter 

cancer control and prevention.

MISSION STATEMENT

10,000 firefighters enrolled 

and followed over 30 years.

TARGET GOAL

Fire Service Oversight and 

Planning Board and firefighter 

research champions in each 

research project.

FIRE SERVICE PARTNERSHIP
136

FFCCS INCLUDES ALL 

TYPES OF 

FIREFIGHTERS

U.S. Fire Administrator’s Summit on Fire Prevention and Control
FFCCS RESEARCH CONCEPTS

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Toxicity

Reduction Treatment Early detection

Exposures Cancer

Prevention

Examples:

Polycyclic aromatic 

hydrocarbons (PAHs), 

PFAS (forever 

chemicals)

Flame retardants

Examples:

DNA damage

Epigenetic 

changes

Anti-müllerian 

hormone (AMH)

Examples:

Identification of 

firefighters at high 

risk for cancer, for 

advanced screening
FFCCS ENROLLMENT TO DATE

U.S. Fire Administrator’s Summit on Fire Prevention and Control

31.1%
FFCCS PROJECTS AND FUNDING

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Funding: Federal Emergency Management Agency (FEMA) EMW-2014-FP-00200, EMW-2015-FP-00213, EMW-2017-FP-00860, EMW2018-FP-00086, EMW-2019-FP-00526, EMW-2019-FP-00517, EMW-2020-FP-00430, National Institute of Environmental Health Sciences 

(NIEHS) P30 ES006694, P30 ES017885, National Institute for Occupational Safety and Health (NIOSH), University of Arizona Cancer 

Center, International Association of Fire Fighters (IAFF), some individual fire departments, and the National Cancer Institute (NCI).

Grant 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

0) Pre-FFCCS

1) Framework

2) Expansion

3) PFAS

4) WUI

5) Women

6) Volunteers

7) PACES

8) Wildland
FFCCS: CONTRIBUTIONS TO DATE AND COMING SOON

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Exposures and Toxic Mechanisms Coming Soon-Evaluation of:

Causing Cancer in Fire Fighters

Prevention & Intervention Coming Soon-Evaluation of:

Everyone on the fireground is 

exposed, including firefighters, 

captains, engineers and 

paramedics1

Firefighter exposures cause 

epigenetic changes associated with 

increased cancer risk2-5

Serum PFAS are elevated in 

volunteer and career firefighters 

and are associated with epigenetic 

changes6-8

Engineers on air (SCBA) and entry 

team wash-down both significantly 

reduce exposure9

Skin wipes reduce firefighter 

exposures and toxic effects10
FFCCS RESEARCH CONCEPTS

Engineers on air (SCBA) and entry 

team wash-down both significantly 

reduce exposure9

Skin wipes reduce firefighter 

exposures and toxic effects10

Prevention & Intervention Coming Soon-Evaluation of:

Firefighter exposures cause 

epigenetic changes associated with 

increased cancer risk2-5

Exposures and Toxic Mechanisms 

Causing Cancer in Fire Fighters

PFAS exposure (from AFFF, fires, 

turnout gear) and toxicity

Cancer risk, stress and reproductive 

toxicity in women firefighters11

Serum PFAS are elevated in 

volunteer and career firefighters 

and are associated with epigenetic 

changes6-8

Everyone on the fireground is 

exposed, including firefighters, 

captains, engineers and 

paramedics1

Exposures and toxicity in WUI & 

wildland firefighters

Toxicity reduction intervention studies

U.S. Fire Administrator’s Summit on Fire Prevention and Control
NEXT STEPS

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 Seek funding to expand participation to 10,000 firefighters and provide for 

long-term follow-up

 Evaluate additional outcomes as requested by fire service

 Further define toxic exposures and mechanisms

 Establish linkages to the NFR

 Expand cancer prevention activities

 Exposure reduction

 Toxicity mitigation
Jeff Burgess, MD, MS, MPH 

jburgess@arizona.edu

Alberto Caban Martinez, PhD, DO, MPH 

Acaban@med.miami.edu

Miriam Calkins, PhD, MS

oii2@cdc.gov

Judith Graber, PhD, MS 

judith.graber@rutgers.edu

Casey Grant, PE, FSFPE 

cgrant@dsrae.net

U.S. Fire Administrator’s Summit on Fire Prevention and Control

CONTACT INFORMATION
U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire 

Prevention and Control

National Emergency Training Center

October 11, 2022
Women Firefighters & Cancer

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Dr. Sara A. Jahnke
In the United States, women 

account for:

 13% of Police

 14% of Military

 6% of Marine Corps

 3.5 % – 5% of Fire & 

Emergency Services

U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire Prevention and Control

0

100

200

300

400

500

600

197019711972197419761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022

"Firefighter" in PubMed
U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire Prevention and Control

Findings: While there was little evidence of excess overall cancer 

mortality among women (SMR=0.74, 95% CI 0.27 to 1.61, n=6), 

most cancer deaths were from breast cancer (SMR=1.46, 95% CI 

0.30 to 4.26, n<5). Bladder cancer mortality was statistically 

significant (SMR=33.51, 95% CI 4.06 to 121.05, n<5) based on 

few cases.

CANCERS IN WOMEN 

FIREFIGHTERS
U.S. Fire Administrator’s Summit on Fire Prevention and Control

 Brain Cancer: aOR=2.54 

(95% CI=1.19-5.42)

 Thyroid: aOR=2.42 (95% 

CI=1.56-3.74)

 Melanoma: aOR=1.68 

(95% CI=0.97-2.90)

CANCERS IN WOMEN 

FIREFIGHTERS
BREAST CANCER RISKS 

U.S. Fire Administrator’s Summit on Fire Prevention and Control

RESEARCH TEAM

Firefighter Organizations: 

 United Fire Service Women

 San Francisco Firefighters Cancer Prevention 

Foundation 

Science Team: 

 UC Berkeley 

 UC San Francisco 

 Silent Spring Institute

Environmental Health Advocates: 

 Breast Cancer Prevention Partners

 Commonwealth
REPRODUCTIVE HEALTH

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 Concerns:

 Chemical, biological, radiologic exposures

 Shift schedule

 Extreme physiological strain of emergency 

response

 High ambient temperature and noise 

 Under-studied

 Little known about: 

 Child health impact

 Occupational exposures for mothers
REPRODUCTIVE HEALTH

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 Recent research: Miscarriage rates 

among female firefighters were at least 

2.3 times higher compared to the U.S. 

National average of 10% (Jung, 2021)

 Volunteer firefighters had a 42% higher 

rate of miscarriage than career
FUTURE OF RESEARCH: 

WOMEN FIREFIGHTERS AND CANCER

U.S. Fire Administrator’s Summit on Fire Prevention and Control
Dr. Sara A. Jahnke

Center for Fire, Rescue, & EMS Health Research

National Development & Research Institutes – USA, Inc.

jahnke@ndri-usa.org

U.S. Fire Administrator’s Summit on Fire Prevention and Control

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U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire 

Prevention and Control

National Emergency Training Center

October 11, 2022
Firefighter Cardiovascular Health

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Denise L. Smith, Ph.D.
 SCE are the leading cause of acute 

duty-related death

 800-1,000 non-fatal events per 

year

 SCE are not random throughout day

 32% of their fatalities occur during 

firefighting but only 1% of time 

spent

 Statistically, 86 times more likely to 

have SCE after FF

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Time Spent Fatalities

Fire Suppression 1% 32%

Response to Alarm 4% 11%

Return from Alarm 7% 4%

Physical Training 8% 20%

Nonfire emergencies 15% 9%

Nonemergency duties 65% 25%

SUDDEN CARDIAC 

EVENTS (SCE)
CURRENT USFA DATA 2020

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Source: USFA-Firefighter Fatalities in the United States 2020
CURRENT USFA DATA 2020

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Source: USFA-Firefighter Fatalities in the United States 2020
U.S. Fire Administrator’s Summit on Fire Prevention and Control

PHYSICAL DEMANDS OF 

THE JOB PHYSIOLOGICAL STRAIN

→ Cardiovascular

→ Hematological 

→ Thermoregulatory

→ Respiratory 

→ Metabolic

→ Immune/Endocrine

→ Nervous 

→ Muscular 

Strenuous 

work

Hot and 

Dangerous 

Environment

Heavy PPE
RESEARCH FRAMEWORK

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Coronary HD

Plaque Rupture and 

Thrombus Formation

Vascular 

Changes Cardiac Stress Blood Thickens

Arrhythmia

Sudden Cardiac Event

Hypertensive HD 

Cardiovascular Strain of Firefighting

Normal Cardiomegaly Normal LVH

Smith et al., 2013 

Recovery
U.S. Fire Administrator’s Summit on Fire Prevention and Control

RESEARCH FINDINGS

Autopsy Findings of Cardiac Death 

Cases and Controls:

Underlying disease

Cardiac

Case

Non-Cardiac 

Control

Coronary artery 

≥50% stenosis 73.2% 18.5%

Heart weight 

>450g 77.2% 32.5%

CVD Risk Factor Prevalence 

Among Firefighters: (%)

Hypertension (n=5063) 69%*

High Cholesterol (n=4513) 20%#

Low HDL (n=4513) 25%#

High Blood Glucose 

(n=4513) 4%#

Obesity (n=4513) 36%#

KEY FINDING – 80% of cardiac deaths 

had both CHD and HHD

KEY FINDINGS – greater hypertension than 

general population, others similar. FF is NOT 

similar to other jobs
FIREFIGHTER CARDIOVASCULAR HEALTH 

U.S. Fire Administrator’s Summit on Fire Prevention and Control

 Firefighting causes significant CV strain and physiological disruption

 Firefighting can Trigger a cardiac event in people with 

underlying disease - especially if FF has CHD and 

hypertensive heart disease

 Firefighters should be screened for underlying CVD

 Firefighters NEED robust fitness and wellness programs 

 Address cardiovascular disease risk factors 

 Prevent cardiovascular disease
Dr. Denise Smith

Tisch Distinguished Professor

Director First Responder Health and Safety Laboratory

Skidmore College, and

Senior Research Scientist 

Illinois Fire Service Institute

dsmith@skidmore.edu

U.S. Fire Administrator’s Summit on Fire Prevention and Control

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U.S. Fire Administrator’s Summit on Fire 

Prevention and Control

National Emergency Training Center

October 11, 2022
Firefighter Behavioral Health

U.S. Fire Administrator’s Summit on Fire Prevention and Control

Pat Morrison
WHERE WE STARTED

U.S. Fire Administrator’s Summit on Fire Prevention and Control
WHAT WE KNOW

 Fire service members experience higher rates of behavioral health disorders, 

when compared to the general population

 Suicide, burnout, and recruitment are major challenges of today

 The connection between behavioral health, sleep, and all other health 

outcomes is indisputable 

 Many barriers still exist that prevent fire fighters from seeking help

 Peer support can effectively bridge the gap to help 

 Fire fighters need culturally informed, evidenced based treatment

 Fire fighters remain highly resilient due to protective factors inherit to the 

occupation 

U.S. Fire Administrator’s Summit on Fire Prevention and Control
WHAT WE DON’T KNOW

 The rate (or cause) of fire fighters that die by suicide

 How to tackle the eroding physiological and cognitive impacts of sleep 

deprivation/shiftwork

 How to translate education/awareness into concrete behavioral change that 

saves lives 

 How to expedite critical behavioral change in a legacy of tradition

 How to attract and retain millennials and Gen Z to the fire service

U.S. Fire Administrator’s Summit on Fire Prevention and Control
Behavioral Health Education

Department-wide Resiliency Training

Peer Support Programming 

Behavioral Health Screening

Comprehensive Health Insurance Coverage

Post- PTE Response

Chaplaincy Program

Vetted Mental Health Providers

Physical Fitness Program

Retiree Inclusion 

Family Inclusion 

ORGANIZATIONAL RESILIENCE

U.S. Fire Administrator’s Summit on Fire Prevention and Control
CREATING A RESILIENT WORKFORCE FOR TOMORROW

Emerging Trends 

 Comprehensive fire department behavioral health programming

 Mandatory behavioral health education for all levels of rank

 Targeted outreach/inclusion of department leaders and recruits 

 Annual behavioral health screening and evaluation 

 Increased treatment access through telehealth 

 Improved treatment outcomes through culturally informed care

 The role of science in cutting edge behavioral health treatments

U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire Prevention and Control
U.S. Fire Administrator’s Summit on Fire Prevention and Control
Pat Morrison

Chief of Field Services

International Association of Fire Fighters

pmorrison@iaff.org

U.S. Fire Administrator’s Summit on Fire Prevention and Control

CONTACT INFORMATION
U.S. Fire Administrator’s Summit on Fire Prevention and Control