HETA 94-0390-2822

Anaheim Fire Department

Anaheim, California

Allison Tepper, PhD

Charles Mueller, MS

Joseph J. Hurrell, Jr., PhD

Daehee Kang, MD, PhD

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
ii

PREFACE

The Hazard Evaluations and Technical Assistance Branch (HETAB) of the National Institute for

Occupational Safety and Health (NIOSH) conducts field investigations of possible health hazards in the

workplace. These investigations are conducted under the authority of Section 20(a)(6) of the Occupational

Safety and Health (OSHA) Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of Health and

Human Services, following a written request from any employer or authorized representative of employees,

to determine whether any substance normally found in the place of employment has potentially toxic effects

in such concentrations as used or found.

HETAB also provides, upon request, technical and consultative assistance to Federal, State, and local

agencies; labor; industry; and other groups or individuals to control occupational health hazards and to

prevent related trauma and disease. Mention of company names or products does not constitute endorsement

by NIOSH.

ACKNOWLEDGMENTS AND AVAILABILITY OF REPORT

This report was prepared by Allison Tepper and Charles Mueller of HETAB, Division of Surveillance,

Hazard Evaluations and Field Studies (DSHEFS) and Joseph J. Hurrell, Jr., Office of the Director, DSHEFS.

Daehee Kang, former HETAB medical officer, was the project officer who led the evaluation. Douglas

Trout, MD, reviewed and interpreted the electrocardiograms. Desktop publishing was performed by Pat

McGraw. Review and preparation for printing were performed by Penny Arthur.

Copies of this report have been sent to employee and management representatives at the Anaheim Fire

Department and the OSHA Regional Office. This report is not copyrighted and may be freely reproduced.

Single copies of this report will be available for a period of three years from the date of this report. To

expedite your request, include a self-addressed mailing label along with your written request to:

NIOSH Publications Office

4676 Columbia Parkway

Cincinnati, Ohio 45226

800-356-4674

After this time, copies may be purchased from the National Technical Information Service (NTIS) at

5825 Port Royal Road, Springfield, Virginia 22161. Information regarding the NTIS stock number may be

obtained from the NIOSH Publications Office at the Cincinnati address.

For the purpose of informing affected employees, copies of this report shall be

posted by the employer in a prominent place accessible to the employees for a

period of 30 calendar days.
iii

Highlights of the NIOSH Health Hazard Evaluation

Heart Problems, Mental Health, and Job Stress in the

Anaheim Fire Department

NIOSH responded to a request for a health hazard evaluation from the International Association of Fire

Fighters. The requestors asked NIOSH to learn if job stressors were related to heart problems and

psychologic changes among fire service personnel.

What NIOSH Did

# We reviewed EKGs (electrocardiograms) done

during annual physical exams.

# We handed out a questionnaire to learn about

job stressors and mental health.

What NIOSH Found

# No one reported having depressive symptoms

or anxiety “very often.”

# Depressive symptoms were related to

uncertainty about career, lack of support from

coworkers, disharmony among coworkers, work

effort, self-reported participation in fires with

multiple burn victims, and years in the fire

department.

# Anxiety was related to uncertainty, disharmony,

work effort, and self-reported hazardous

materials exposure and participation in fires

with multiple burn victims.

# The EKGs of 48 participants were rated as

abnormal by the NIOSH physician. Sinus

arrhythmia, the most common abnormality, was

found in 23 participants. Sinus arrhythmia is a

normal variant, and is harmless in most people.

What Anaheim Fire Department

Managers Can Do

# Provide mandatory annual medical evaluations

and periodic physical examinations following

the NFPA Standard on Medical Requirements.

# Ensure that EKGs are reviewed by a physician,

and that the medical record includes the

physician’s interpretation. Provide appropriate

medical follow-up for findings of clinical

significance.

# Provide a mandatory wellness/fitness program

to reduce risk factors for cardiovascular disease

and improve cardiovascular capacity.

# Implement a program to reduce job stress. 

What Anaheim Fire Department

Employees Can Do

# Participate in annual medical evaluations and

periodic physical examinations, and a

wellness/fitness program offered by the Fire

Department.

# Report concerns about job stressors to your

supervisor, and get involved in work stress

prevention programs.

CDC CENTERS FOR DISEASE CONTROL

AND PREVENTION

What To Do For More Information:

We encourage you to read the full report. If you

would like a copy, either ask your health and

safety representative to make you a copy or call

1-513/841-4252 and ask for

 HETA Report # 94-0390-2822
iv

Health Hazard Evaluation Report 94-0390-2822

Anaheim Fire Department

Anaheim, California

September 2000

Allison Tepper

Joseph J. Hurrell, Jr.

Charles Mueller

Daehee Kang

SUMMARY

On August 24, 1994, the National Institute for Occupational Safety and Health (NIOSH) received a request for a

health hazard evaluation (HHE) from the International Association of Fire Fighters (IAFF) Local 2899. Local 2899

represents fire service personnel in the Anaheim Fire Department (AFD) in Anaheim, California. The request

concerned psychologic changes and cardiac abnormalities possibly related to job stress from long work hours, night

work, sleep deprivation, and other job stressors.

On November 16, 1994, NIOSH investigators met with AFD and IAFF representatives to discuss the HHE request

and to visit three fire stations. The meeting and visits were held for NIOSH investigators to learn about AFD work

practices and work organization. On May 31, 1995, NIOSH representatives returned to Anaheim to obtain

electrocardiogram (EKG) results from annual physical examinations and to carry out a health survey. 

NIOSH investigators conducted a questionnaire survey of full-time AFD employees. Participants filled out a

questionnaire about personal characteristics, job history, medical history, cardiovascular symptoms, mental health

(including depressive symptoms and anxiety), and job stress. For all study participants, NIOSH investigators

obtained EKG results from the most recent annual physical examinations. A NIOSH occupational physician read

the EKGs using standard clinical criteria. We did statistical modeling to learn whether job stressors were related

to depressive symptoms, anxiety, and sinus arrhythmia.

Two hundred ten (81%) of 260 full-time employees participated in the questionnaire survey. For this evaluation,

we analyzed the data for the 196 participants who worked in one of the 10 fire stations. All but three participants

were male, and the majority (75%) were in their 30s and 40s. Most participants were in one of the following four

job titles: firefighter (66 persons, 34%), firefighter/paramedic (31 persons, 16%), fire engineer (31 persons, 16%),

and fire captain (30 persons, 15%).

On average, participants reported that depressive symptoms occurred “occasionally” during the past month. None

of the participants reported having depressive symptoms “very often.” Depressive symptoms were related to

uncertainty about career, lack of support from coworkers, disharmony among coworkers, work effort, participation

in fires with multiple burn victims, and years in the fire department.
v

On average, participants reported that anxiety symptoms occurred “occasionally” during the past month. None of

the participants reported having anxiety “very often.” Anxiety was related to uncertainty about career, lack of

support from coworkers, disharmony among coworkers, work effort, self-reported hazardous materials exposure,

and participation in fires with multiple burn victims.

EKGs were available for 179 of the 196 participants working in a fire station. The NIOSH physician reported that

73% (131 persons) were within normal limits and 27% (48 persons) were abnormal. The NIOSH physician noted

several EKG abnormalities; the most common was sinus arrhythmia, occurring in 23 participants. The only other

abnormalities noted in more than five participants were sinus bradycardia (11 persons) and conduction delay (10

persons). Due to the small number of participants with any single condition other than sinus arrhythmia, we

focused further analysis on this finding. We did not find a meaningful linear relationship (that is, more job stress

associated with more sinus arrhythmia) between sinus arrhythmia and any of the job stressors studied.

Our evaluation found neither severe psychological problems nor a consistent pattern of clinically

significant cardiac arrhythmias. We did, however, find evidence that certain aspects of the job affected

the psychologic well-being of employees. These included the job stressors of uncertainty, disharmony,

and work effort, and involvement in specific critical incidents, including fires with multiple burn victims

and self-reported hazardous materials exposure. Recommendations are offered to ensure that Anaheim

Fire Department personnel are receiving appropriate medical surveillance and to address concerns about

job stress.

KEYWORDS: SIC 9224 (Fire Protection), job stress, cardiovascular disease, arrhythmia, anxiety, depressive

symptoms, depression
vi

TABLE OF CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Acknowledgments and Availability of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

HHE Supplement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Introduction ......................................................................... 1

Background ......................................................................... 1

Methods ........................................................................... 1

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Health Hazard Evaluation Report No. 94-0390-2822 Page 1

INTRODUCTION

On August 24, 1994, the National Institute for

Occupational Safety and Health (NIOSH) received a

request for a health hazard evaluation (HHE) from

the International Association of Fire Fighters (IAFF)

Local 2899. Local 2899 represents fire service

personnel in the Anaheim Fire Department (AFD) in

Anaheim, California. The request concerned

psychologic changes and cardiac abnormalities

possibly related to job stress from long work hours,

night work, sleep deprivation, and other job

stressors.

On November 16, 1994, NIOSH investigators met

with AFD and IAFF representatives to discuss the

HHE request and to visit three fire stations. The

meeting and visits were held for NIOSH

investigators to learn about AFD work practices and

work organization. On May 31, 1995, NIOSH

representatives returned to Anaheim to obtain

electrocardiogram (EKG) results from annual

physical examinations and to carry out a health

survey.

BACKGROUND

At the time of the NIOSH investigation, the AFD

had 260 full-time employees. AFD facilities

comprised administrative offices, a dispatch center,

a training facility, and 10 fire stations. These stations

housed 12 engine companies (nine of which were

paramedic) and five truck companies. The AFD

served more than 293,000 people in a 49.5-squaremile area. Fire service personnel responded to more

than 23,000 emergency services calls per year. The

AFD classified these calls as medical (61%), false

alarms (22%), service (8%), fire-related (6%), and

hazardous conditions (3%). AFD employees also

conducted approximately 14,000 fire inspections and

more than 6,000 fire hydrant tests.

METHODS

We conducted a questionnaire survey of full-time

AFD employees. We handed out the questionnaire

to employees who reported to a central location in

groups of 20-40, and we were present to answer

questions and assure that questionnaires were

completed correctly. Questionnaires were left at the

site for distribution to employees not present during

the NIOSH visit; employees who completed the

forms mailed them to NIOSH.

The questionnaire addressed personal characteristics,

job history, medical history, cardiovascular

symptoms, mental health (including depressive

symptoms and anxiety), and job stress. Questions

about mental health and job stress were from the

NIOSH generic job stress questionnaire.1

 

The health outcomes we considered were depressive

symptoms and anxiety. Individual questions

(described below) used to measure these outcomes

were rated on a five-point scale, where 1=never and

5=very often. Responses to individual questions

were summarized to create a scale for each of these

outcomes. We used factor analysis to identify items

for each scale, then computed coefficient alpha to

describe how well the items in each scale were

related to each other. Scales with an alpha

coefficient of at least 0.70 are considered to be

reliable for the type of study we did.2

• The scale for depressive symptoms included seven

items. Respondents were asked how they

experienced each of the following during the past

month: “could not shake off the blues,” “trouble

keeping my mind on what I was doing,” “felt

depressed,” “felt fearful,” “felt lonely,” “felt sad,”

and “talked less than usual.” The alpha was 0.89.

• The scale for anxiety included 10 items.

Respondents were asked how often they experienced

each of the following during the past month:

“flushing of your face,” “dry mouth,” “clear your

throat often,” “choking lump in your throat,” “tight

and tense muscle,” “headache,” “trembled hand,”
Page 2 Health Hazard Evaluation Report No. 94-0390-2822

“damp and clammy hand,” “poor appetite,” and

“sleep was restless.” The alpha was 0.79.

The general job stressors we considered (described

below) included uncertainty, disharmony, task

control, job control, work effort, work threat, work

variance, and mental demands. Individual questions

used to measure these stressors were rated on a scale

of 1-5 (for all except mental demands, which was

rated on a 1-4 scale), and responses were

summarized to create a scale for each stressor, as

above.

• The scale for uncertainty included six items.

Respondents were asked whether they agreed or

disagreed with each of the following items: “certain

about what my future career picture looks like,”

“certain of the opportunities for promotion and

advancement,” “certain that I am valued by the staff

members,” “certain that the staff members will help

to solve problems,” “certain that the staff will help

and protect me if I am injured on duty,” and “certain

that staff will help me achieve my goals.” The alpha

was 0.82.

• The scale for disharmony included seven items.

Respondents were asked whether they agreed or

disagreed with each of the following items:

“harmony within my fire station on my shift,”

“harmony within my fire station on all shifts,”

“clashes between units at my station,” “clashes

between crew and staff,” “disputes between my

station and other stations,” “other stations create

problems for my station,” and “problems working

with other city fire units.” The alpha was 0.75. 

• The scale for task control included two items.

Respondents were asked how much influence they

had over each of the following items: “the amount of

work” and “the pace.” The alpha was 0.77. 

• The scale for job control included three items.

Respondents were asked how much influence they

had over each of the following items: “decisions

concerning which individuals...do which tasks,”

“policies, procedures that affect your unit,” and

“work and work-related factors.” The alpha was

0.79.

• The scale for work effort included four items.

Respondents were asked how often the job required

them to do each of the following items: “work very

fast,” “work very hard,” “think and react very fast,”

and “be alert continuously.” The alpha was 0.73.

• The scale for work threat included two items.

Respondents were asked how often the job exposed

them to each of the following items: “threat of

physical harm or injury” and “threat of violence.”

The alpha was 0.80. 

• The scale for work variance included four items.

Respondents were asked how often each of the

following happened: “great deal of work,” “marked

increase in the workload,” “marked increase in the

amount of concentration,” and “receive extra

projects.” The alpha was 0.76 .

• The scale for mental demands included three

items. Respondents were asked whether they agreed

or disagreed with each of the following items: “job

requires a great deal of concentration,” “job requires

me to remember many different things,” and “keep

my mind on my work at all times while on call.”

The alpha was 0.77.

We also considered job stressors specific to

firefighters and paramedics, that is involvement in

certain types of critical incidents. These included

fires with multiple burn victims, injury of co-workers

on duty, hazardous materials and infectious agents

exposures, motor vehicle accidents with fatalities,

sudden infant death, and friends or relatives as

victims, among others.3

 Participants were asked

whether they had experienced each of these events

during the past year. Independent, objective

information was not obtained.

NIOSH investigators obtained EKG

(electrocardiogram) results from the most recent

annual physical examinations for all study 
Health Hazard Evaluation Report No. 94-0390-2822 Page 3

participants. These EKGs were done under contract

to the AFD; a machine reading classified the results

as within normal limits, abnormal, or borderline. A

NIOSH occupational physician, who is also certified

in internal medicine, read the EKGs using standard

clinical criteria.4

 EKG abnormalities were classified

as sinus arrhythmia, sinus bradycardia, conduction

delay, ischemia, arrhythmia, hypertrophy, right axis

deviation, and left axis deviation.

We did statistical modeling to learn whether job

stressors were related to depressive symptoms,

anxiety, and sinus arrhythmia. We used one type of

model, linear regression, for the depressive

symptoms and anxiety outcomes and used another

type of model, logistic regression, for the sinus

arrhythmia outcome. The statistical significance of

the relationship is gauged by the p value. A p value

less than or equal to 0.05 is considered statistically

significant and indicates that one can be confident

that a relationship exists between the stressor and the

outcome. For each outcome, we began our modeling

by examining the relationship between that outcome

and the job stressors, taken one at a time, while

taking into account nonoccupational factors (age,

race, marital status, primary responsibility for child

care). Next, any job stressors which appeared to be

related to the outcome in our initial models were

studied further in models that evaluated their

combined effects.

RESULTS

Two hundred ten (81%) of 260 full-time employees

participated in the questionnaire survey. One

hundred ninety-seven participants worked in one of

the 10 fire stations, with the rest working in

administrative offices, the dispatch center, training,

and fire prevention. The following results include

only the 196 assigned to a fire station. All but three

were male. Ten % (20 persons) were in their 20s,

47 % (93 persons) in their 30s, 28% (54 persons) in

their 40s, and 15% (29 persons) in their 50s.

Participants worked an average of 14 years in the

AFD (range: 10 months - 32 years). Seventy-eight %

of participants were in one of the following four job

titles: firefighter (66 persons, 34%),

firefighter/paramedic (31 persons, 16%), fire

engineer (31 persons, 16%), and fire captain (30

persons, 15%). Other job titles with 10 or more

participants each were engineer/paramedic and fire

captain/paramedic. 

The average and range for the job stressor scales is

shown in Table 1. Twenty-eight % (54 persons)

agreed moderately or strongly that they had

uncertainty about career and support from coworkers

and had disharmony among coworkers. While 15%

(29 persons) reported little or very little task control,

53% (104 persons) reported little or very little job

control. Seventy-four % (145 persons) reported

experiencing hard or fast work often or very often,

68% reported on-the-job-threats often or very often,

and 48% (93 persons) reported increased work load

or need for concentration often or very often.

Eighty-three % (160 persons) strongly agreed about

the presence of mental demands.

Information about involvement in critical incidents is

shown in Table 2. The frequency of encountering

these incidents in the past year was high, ranging

from 36% (sudden infant death, fire with multiple

burn victims) to 98% (drug overdose). 

The mean score for depressive symptoms was 1.86,

that is, on average, participants reported that

depressive symptoms occurred “occasionally” during

the past month. Individual scores ranged from 1.0-

4.4; none of the participants reported having

depressive symptoms “very often.” In the final

statistical model, depressive symptoms were related

to uncertainty (p<0.01), disharmony (p=0.04), work

effort (p=0.03), fire with multiple burn victims

(p<0.01), and years in the fire department (p<0.01).

When we included the nonoccupational factors in the

statistical model, these findings were very similar.

The mean score for anxiety was 1.9, that is, on

average, participants reported that anxiety symptoms

occurred “occasionally” during the past month.

Individual scores ranged from 1.0 to 3.3; none of the
Page 4 Health Hazard Evaluation Report No. 94-0390-2822

participants reported having anxiety “very often.” In

the final statistical model, anxiety was related to

uncertainty (p<0.01), disharmony (p=0.02), work

effort (p<0.01), hazardous materials exposure

(p=0.01), and fire with multiple burn victims

(p=0.06). When we included the nonoccupational

factors in the statistical model, these findings were

very similar.

EKGs were available for 179 of the 196 participants

working in a fire station. According to the machine

reading of the EKG, 37% (67 persons) were within

normal limits, 27% (48 persons) were abnormal,

35% (63 persons) were borderline, and 1% (one

person) had inadequate data. The NIOSH physician

reported that 73% (131 persons) were within normal

limits and 27% (48 persons) were abnormal. Of

those classified as normal by the machine reading,

87% were rated similarly by the NIOSH physician.

In contrast, of those classified as abnormal by the

machine reading, 54% were rated similarly by

NIOSH physician. The NIOSH physician noted

several EKG abnormalities; the most common was

sinus arrhythmia, occurring in 23 participants. The

only other abnormalities noted in more than five

participants were sinus bradycardia (11 persons) and

conduction delay (10 persons). Due to the small

number of participants with any single condition

other than sinus arrhythmia, we focused further

analysis on this finding. We did not find a

meaningful linear relationship (that is, more job

stress associated with more sinus arrhythmia)

between sinus arrhythmia and any of the job

stressors studied.

DISCUSSION

The initial concerns raised in the HHE request

related to cardiovascular effects, specifically cardiac

arrhythmias, and psychologic changes among AFD

personnel. Our evaluation found neither severe

psychological problems nor a consistent pattern of

clinically significant cardiac arrhythmias. We did,

however, find evidence that certain aspects of the job

affected the psychologic well-being of employees.

The fire service is recognized as a high stress job, as

firefighters and emergency medical personnel

routinely are placed in demanding situations and

high-risk environments.5

 In addition, fire service

employees typically work long hours involving

complex shift schedules. While much attention has

been paid to the psychological effects of acute

stressors in traumatic fire and rescue responses

(critical incidents), some evidence suggests that

chronic stressors such as sleep disruption, concerns

about wages and benefits, labor/management issues,

and personal safety, among others, may be more

important elements of perceived stress in fire service

personnel.6

 We found that both types of job stressors

were predictors of depressive symptoms and anxiety.

Job stresses, in addition to exposure to hazardous

agents such as carbon monoxide and the physical

requirements of the work, may pose a risk for the

development of cardiovascular disease.7

 No studies,

however, have looked at the long-term effects of job

stress on cardiovascular disease in firefighters.

Several different types of studies have been done to

look in general at the association between

firefighting and cardiovascular disease; most have

been studies of firefighter deaths. As discussed in

the review by Melius, some studies have found an

increased risk of cardiovascular deaths in

firefighters, but others have not.7

 The differences

may be due to varying study methods and to the

difficulties inherent in epidemiologic studies that

compare the mortality experience of working

populations to that of the general population.7,8

Arrhythmia is a general term that includes many

specific abnormaliies of heart rhythm, including

normal variants. Some are serious, others are not.

Sinus arrhythmia, the condition we found in the

greatest number of participants usually is a normal

variant.9

 Sinus arrhythmia is one of the most

common arrhythmias and, in the majority of people,

is harmless.10 While the NIOSH physician also

found other types of electrocardiogram

abnormalities, their relative frequency did not appear

to be unusual. The apparent discrepancy between

the machine readings and those of the NIOSH

physician is, in part, due to differences in criteria
Health Hazard Evaluation Report No. 94-0390-2822 Page 5

used to define abnormality. It is likely that the

machine is set up to pick up any aberration in cardiac

electrical activity so that an individual can be

referred to a physician for followup. Many of those

EKGs identified as abnormal by the machine reading

may turn out not to represent a clinically significant

condition, but the machine reading would

presumable have a low likelihood of missing

someone who does have a clinically significant

condition. Other factors contributing to the

discrepancy could not be determined.

Researchers have looked at the effects of various

types of stress on sinus arrhythmia, and have used

specific characteristics of sinus arrhythmia as an

index of stress.11,12 The clinical significance of this

approach, however, and its use in explaining how

stress effects cardiovascular disease, particularly in

healthy persons, however, is not well established.

We did not find that the occurrence of sinus

arrhythmia was related to any of the stressors we

measured in AFD personnel.

CONCLUSIONS

Our evaluation found neither severe psychological

problems nor a consistent pattern of clinically

significant cardiac arrhythmias among Anaheim fire

service personnel. We did find, however, evidence

that certain aspects of the job affected the

psychologic well-being of employees. These

included the job stressors of uncertainty,

disharmony, and work effort, and involvement in

specific critical incidents, including fires with

multiple burn victims and hazardous materials

exposure.

RECOMMENDATIONS

The following recommendations address health and

safety in the fire service generally. These

recommendations should be reviewed to assess

whether current AFD programs are consistent.

1. Fire fighters should have mandatory annual

medical evaluations and periodic physical

examinations to determine their medical ability to

perform duties without presenting a significant risk

to the safety and health of themselves or others. 

Guidance regarding the content and frequency of

periodic medical evaluations for fire fighters can be

found in NFPA 1582, Standard on Medical

Requirements for Fire Fighters and Information for

Fire Department Physicians,13 and in the report of the

IAFF/International Association of Fire Chiefs

(IAFC) wellness/fitness initiative.14 These

recommendations have not been evaluated by

NIOSH, but represent published research or of

consensus votes of Technical Committees of the

National Fire Protection Association or

labor/management groups within the fire service.

EKGs machine-read as abnormal or borderline

should be reviewed by a physician, and the medical

record should include the physician’s interpretation.

Findings of clinical significance should trigger

appropriate medical follow-up.

2. The Fire Department should offer a mandatory

wellness/fitness program for fire fighters to reduce

risk factors for cardiovascular disease and improve

cardiovascular capacity.

NFPA 1500, Standard on Fire Department

Occupational Safety and Health Program, requires a

wellness program that provides health promotion

activities for preventing health problems and

enhancing overall well-being.15 In 1997, the IAFF

and the IAFC began an initiative to improve fire

fighter quality of life and maintain physical and

mental capabilities of fire fighters.14 Ten fire

departments across the United States joined this

effort to pool information about their physical fitness

programs and to create a practical fire service

program. They produced a manual and a video

detailing elements of such a program. This program

can serve as a model for a comprehensive wellness

program. 
Page 6 Health Hazard Evaluation Report No. 94-0390-2822

1. Hurrell JJ, Jr, McLaney MA [1988].

Exposure to job stress - A new psychometric

instrument. Scand J Work Environ Health

14:(suppl 1) 27-28.

2. Nunnaly J [1978]. Psychometric theory.

New York: McGraw-Hill.

3. Beaton R,Murphy S, Johnson C, Pike K,

Corneil W [1988]. Exposure to duty-related

incident stressors in urban firefighters and

paramedics. J Trauma Stress 11:821-828.

4. Scheidt S, Erlebacher JA [1986]. Basic

Electrocardiography. West Caldwell, New Jersey:

CIBA-GEIGY.

5. Barnhart S, Pappas GP [1998]. Firefighters’

health and safety. In Rom WM. Environmental

and Occupational Medicine. Third Edition.

Philadelphia:Lippincott-Raven. pp. 1455-1464.

6. Gist R, Woodall SJ [1995]. Occupational

stress in contemporary fire service. Occupational

Medicine: State of the Art Reviews. Vol. 10, No.

4. Philadelphia: Hanley & Belfus, pp. 763-788.

7. Melius JM [1995]. Cardiovascular disease

among firefighters. In. Occupational Medicine:

State of the Art Reviews Vol. 10, No. 4.

Philadelphia: Hanley & Belfus, pp. 821-827.

8. Monson RR [1990]. Occupational

Epidemiology. 2nd Ed. Boca Raton, Florida: CRC

Press.

9. Zipes DP [1988]. Specific arrhythmias:

diagnosis and treatment. In. Heart Disease. A

textbook of Cardiovascular Medicine. Third Ed.

Philadelphia: W. B. Saunders Company, p. 665.

10. Anonymous. [1995]. Facts about

arrhythmias/rhythm disorders. Bethesda,

Maryland: National Heart, Lung, and Blood

Institute. NIH Publication No. 95-2264.

11. Porges SW [1995]. Cardiac vagal tone: a

physiological index of stress. Neurosci Biobehav

Rev 19:225-233.

12. Lane JD, Adcock RA, Burnett RE [1992].

Respiratory sinus arrhythmia and cardiovascular

responses to stress. Psychophysiology 29:461-

470.

13. National Fire Protection Association. NFPA

1582, Standard on Medical Requirements for Fire

Fighters and Information for Fire Department

Physicians. NFPA, Quincy MA, 2000. 

14. International Association of Fire Fighters.

The fire service joint labor management

wellness/fitness initiative. International

Association of Fire Fighters, Department of

Occupational Health and Safety, Washington DC,

1997. NFPA, Quincy MA, 1997.

15. National Fire Protection Association. NFPA

1500, Standard on Fire Department Occupational

Safety and Health Program. NFPA, Quincy MA,

1997.

16. NIOSH [1999]. Stress at Work. Cincinnati,

OH: US Department of Health and Human

3. The Fire Department should implement a

program to reduce job stress. Generally, a program

that addresses organizational change and stress

management is most useful for preventing stress at

work.16 Before a program is established, it is

essential to raise awareness about job stress, secure

management commitment and support, incorporate

employee involvement, and provide for appropriate

technical support (through training of existing staff,

or the hiring of consultants). The process for stress

prevention programs involves three steps: problem

identification, intervention, and evaluation. Job

stress prevention should be seen as a continuous

process.

REFERENCES
Health Hazard Evaluation Report No. 94-0390-2822 Page 7

Services, Public Health service, Centers for

Disease Control and Prevention, National Institute

for Occupational safety and Health.

DHHS(NIOSH) Publication No. 99-101.
Page 8 Health Hazard Evaluation Report No. 94-0390-2822

TABLE 1

Summary of General Job Stressors in Anaheim Fire Department Personnela

May 1995

HETA 94-0390-2822

Job Stressor Score

Average Range

Uncertainty about future, advancement opportunities, value to

coworkers, support from coworkersb

 2.9 1.0 - 5.0 

Disharmony between coworkers at my station and with workers at other

stationsb

 2.5 2.4 - 4.6

Task control, that is, influence over amount or pace of workc 3.3 1.0 - 5.0

Job control, that is, influence of job assignments, policies, proceduresc 2.5 1.0 - 5.0

Work effort, that is, job often requires me to work very hard or fast,

think and react fast, and be continuously alertd

 3.8 2.0 - 5.0

Work threat, that is, job exposes me to the threat of physical harm or

injury, or violenced

 3.6 1.5 - 5.0

Work variance, that is, there is often a great deal of work or a marked

increase in workload or in the concentration needed for the jobd

 3.3 1.3 - 5.0

Mental demands, that is, requires a lot of concentration or remembering

many thingse

 1.3 1.0 - 4.0

a

Based on a questionnaire survey of 196 fire service personnel

b

Scale ranged from 1 (strongly disagree) - 5 (strongly agree)

c

Scale ranged from 1 (very little) - 5 (very much)

d

Scale ranged from 1 (rarely) - 5 (very often)

e

Scale ranged from 1 (strongly agree) - 4 (strongly disagree)
Health Hazard Evaluation Report No. 94-0390-2822 Page 9

TABLE 2

Summary of Self-reported Fire Service Job Stressors in Anaheim Fire Department Personnela

May 1995

HETA 94-0390-2822

Stressor Persons Having

the Experience

at Least Once in

the Past Year

Stressor Persons Having

the Experience

at Least Once in

the Past Year

No. % No. %

Drug overdose 192 98 Homicide 112 57

CPR with family present 182 93 Victim resembles self or kin 104 54

Failed resuscitation 181 92 Assaulted by patient 97 50

Seriously injured child 169 87 Failed resuscitation on child 97 49

Injury of coworker on duty 170 87 Sexual assault 89 45

Hazardous materials exposure 167 86 Victim is friend of relative 77 39

Suicide 155 79 Sudden infant death 70 36

Infectious agents exposure 148 77 Fire with multiple burn victims 71 36

Fatal motor vehicle accident 144 73

a

Based on a questionnaire survey of 196 fire service personnel
For Information on Other

Occupational Safety and Health Concerns

Call NIOSH at:

1–800–35–NIOSH (356–4674)

or visit the NIOSH Web site at:

www.cdc.gov/niosh

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