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EMPLOYEE HEALTH & INDUSTRIAL MEDICINE CAMBRIDGE HEALT

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EMPLOYEE HEALTH & INDUSTRIAL MEDICINE CAMBRIDGE HEALTH ALLIANCE. ASSISTANT PROFESSOR OF MEDICINE ... OCCUPATIONAL & ENVIRONMENTAL MEDICINE RESIDENCY, HARVARD ... – PowerPoint PPT presentation

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Title: EMPLOYEE HEALTH & INDUSTRIAL MEDICINE CAMBRIDGE HEALT


1
Heart Disease in Firefighters
  • STEFANOS N. KALES, MD, MPH, FACP, FACOEM
  • MEDICAL DIRECTOR
  • EMPLOYEE HEALTH INDUSTRIAL MEDICINE CAMBRIDGE
    HEALTH ALLIANCE
  • ASSISTANT PROFESSOR OF MEDICINE
  • HARVARD MEDICAL SCHOOL
  • ASSISTANT PROFESSOR DIRECTOR,
  • OCCUPATIONAL ENVIRONMENTAL MEDICINE RESIDENCY,
    HARVARD SCHOOL OF PUBLIC HEALTH

2
Background
  • More than one million firefighters in US
  • About 100 firefighters die each year on-Duty
    (1 in 10,000 per year)
  • 1977-2004, CVD has caused 45 on-Duty Deaths
  • CHD 40

3
US Firefighter Fatalities
  • 45 Heart Disease
  • 25 Motor Vehicle Related
  • 12 Asphyxiation
  • 18 Burns, Other Trauma, other

4
Heart Deaths by Occupation
  • of On-Duty Deaths
  • caused by CVD
  • Firefighters 45
  • Police 22
  • Overall 15
  • Construction 11.5
  • EMS 11
  • Average of all Occupational Fatalities,
  • all industries

5
Development of Atherosclerotic Plaques
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus
6
THEORETICAL MODEL OF CVD
Hypertrophy /- Known CHD
Subclinical Disease
Death Disease Disability
Regular Exercise/ activity Moderate EtOH Diet
- / Tobacco - Irregular Physical Exertion
-Pollution/Gases - Noise - Shift Work - Job
Stress with Low Control -
Pro-Inflammatory (bad) Anti-Inflammatory
(good)
7
Cohort Studies vs. Presumption Laws
  • Definitive evidence of an increased CHD risk in
    Firefighters lacking.
  • Based on gt/10 cohort mortality studies
    Firefighters risk of CHD Death
  • SMR of 0.9
  • High proportion of CHD deaths and recognition of
    Cardiovascular Stressors has led to
  • Heart Presumption laws in 37 / 50 states and 2
    Canadian Provinces

8
On-Duty Events, Work-Related or Just happen at
Work??? Potential Occupational Cardiovascular
Stressors
  • Heavy Physical Exertion - on an Irregular Basis
  • gt 50 lbs Personal Protective Equipment
  • Near Maximal-Maximal HR (at least 10 METS)
  • Heat Stress Fluid losses

9
Methods Case-control study, 52 male firefighters
CHD deaths investigated by NIOSH. Control
population 51 male firefighters on-duty trauma
deaths
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U.S. Fire Administration narrative summaries all
US firefighting deaths 1994-2004 (n
1144) Excluded deaths associated September 11,
2001 Classified as cardiovascular or
noncardiovascular Excluded deaths more than 24
hours after the on-duty incident Excluded
cardiovascular deaths other than CHD 449 deaths
due to CHD (39). Selected deaths classified
according to the specific duty performed during
onset of symptoms/ immediately preceding sudden
death.
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Duty-related Risks Interpretation
  • Fire Suppression Heavy Physical Exertion,
  • gt 50 lbs PPE, Near Maximal, Heat Stress Fluid
    losses, Smoke Exposure, Danger Stress
  • Training Risk concentrated in live-fire/simulatio
    n drills (exposures as above)
  • Physical testing in persons without adequate
    medical clearance.
  • Alarm Response Fight or Flight physiology with
    full cardiovascular arousal, Noise

22
On-Duty CHD Death Work-related? Conclusions
  • Both circadian and job activity data support that
    on-duty CHD death is often job-precipitated.
  • Events within a day of firefighting or onset
    during strenuous duty resulting in
    cardiovascular arousal support work-relatedness.
  • Does not include
  • Non-emergency duty, Most EMS work, Off-duty

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CHD Death Risk by Age and Duty
25
Potential Personal Cardiovascular Risk Factors
  • Poor exercise tolerance
  • High prevalences of obesity and
    hypercholesterolemia
  • Hypertension and Dyslipidemia often untreated
  • Most firefighters do not receive regular periodic
    examinations

26
Obesity Trends Among U.S. Adults 1991, 1996,
2003 (CDC)
(BMI ?30, or about 30 lbs overweight for 54
person)
1996
2003
No Data lt10 1014 1519
2024 25
27
Obesity Trends Among U.S. Adults 2006 (CDC)
No Data lt10 1014
1519 2024 2529
30
28
1996- Present Obesity Prevalence 30-40
Professionals 45 Volunteers (NVFC)
29
OBESITY
  • Adverse Effects in Firefighters
  • Blood Pressure
  • Pulmonary Function
  • Exercise Tolerance
  • Lipids
  • Liver Function
  • Cardiovascular Risk Factor clustering
  • Adverse Employment Outcomes

30
Independent Adverse Associations of Hypertension
in Firefighters
31
  • Reviewed all completed fatality reports on NIOSH
    website from 1996- December 2002.
  • 52 male firefighters who died of CHD
  • (69 autopsies 12 known pre-morbid CHD)
  • 310 firefighters examined in 1996 and documented
    as professionally active in firefighting in 1998

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34
Heart Retirements
  • Describe Massachusetts firefighters receiving
    pensions under state Heart Presumption
    legislation
  • 1997-2004 All cases approved by PERAC after
    review by PERAC-appointed medical panels.

35
Research Plan
  • Controls Active- Non-retired Firefighters drawn
    from all regions of Massachusetts
  • 310 male firefighters examined in 1996/1997,
    whose vital status and continued professional
    activity were re-documented in 1998.

36
Results
  • 362 Heart presumption retirements
  • 278 CHD retirements (77)
  • 84 Non-CHD retirements
  • HTN 30 (36)
  • AFIB, Flutter or SVT 19 (23)
  • Cardiomyopathy 11 (13)
  • CVA 11 (13)
  • Syncope 5 (6)
  • Aortic Aneurysm 4 (5)
  • Other 4 (5)

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Predictors of Fatal on-Duty CHD Events (vs.
Non-Fatal Events)
40
A. Fire Fighter Fatality Investigation and
Prevention Program of NIOSH On-Duty Fatalities
reported between January 1996 and July 2006.
B. Massachusetts Heart Disease Disability
Pensions received between 1997 and 2004. 362
Pension Awardees
84 non-CHD Pensions
NON-Cardiovascular Deaths
288 CHD Pensions
110 Cardiovascular Deaths
5 deaths gt 24 hours from event
173 CHD pensions NOT related to a specific
on-Duty event
105 Acute Cardiovascular Deaths within 24 hours
115 CHD Pensions linked to Specific On-Duty Events
14 Non- CHD Deaths
1 Cocaine Related Death
2 Fatalities
90 Acute On-Duty CHD Fatalities (cases)
113 Non-Fatal, On-Duty CHD Events (controls)
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Multivariate Odds Ratios adjusted for all other
Risk Factors in the table, as well as
professional status, age above/below 45 years and
strenuous duty.
45
PREVENTION 1
  • Fitness Promotion
  • Physical Standards not maintained high
    prevalence of obesity (gt33)
  • 75 Nationally- NO fitness programs
  • Mandatory exercise programs
  • Nutrition programs
  • Flu Shots

46
USA Today Wed, August 29, 2007 Firefighters
plagued by heart attacks get fitness challenge
I would rather fire you for your health than to
go tell your wife or your mother that you're
laying out here with a heart attack, dead" Chief
Jolley
Each quarter, Pelham-Batesville (SC) firefighters
take a test that includes running, push-ups,
sit-ups and a flexibility test.
47
PREVENTION 2
  • Medical Screening
  • Few CHD fatalities or Retirements had a FD
    medical w/in 48 months of their event
  • Ideally should integrate occupational exams with
    primary care follow-up

48
CHD Death Risk by Age and Duty
49
PREVENTION 3
  • Risk Factor Reduction
  • Low rates of HTN and lipid treatment
  • Change Blood Pressure Standards
  • Data supports Smoking BAN
  • Exercise Testing
  • Should be mandated gt45 and sooner if excess risk
    factors, study needed to determine best protocols

50
PREVENTION 4
  • 5) RTW Protocols
  • Need Occupational Medicine Clearance after
    Illness or Injury
  • 6) Pre-Existing CHD
  • Once CHD is diagnosed, most affected
    Firefighters should be removed from Emergency
    Operations

51
  • Major Study Team Members 1996-2007
  • Elpidoforos Soteriades, MD, MSc, ScD
  • Jonathan Holder, DO, MPH
  • Costas Christophi, PhD
  • Ibe Mbanu MD, MPH
  • Jesse Geibe, MD, MPH
  • Gerry Polyhronopoulos, MD
  • Jon Aldrich, MD
  • Stavros Christoudias
  • Antonios Tsismenakis
  • David Christiani, MD, MPH, MS Professor
    Director Occupational Health Program, HSPH

52
  • Bibliography
  • Kales SN, Polyhronopoulos GN, Aldrich JM, Leitao
    ED, Christiani DC. Correlates of body mass index
    in hazardous materials firefighters. J Occup and
    Environ Med 199941 589-595.
  • Kales SN, Christiani DC. Cardiovascular Fitness
    in Firefighters. Journal of Occupational and
    Environmental Medicine 2000 42 467-468.
  • Kales SN, Soteriades ES, Christoudias SG, Tucker
    S, Nicolaou M, Christiani DC. Firefighters blood
    pressure and Employment Status on Hazardous
    Materials Teams in Massachusetts A Prospective
    Study. J Occup Env Med 200244669-676.
  • Soteriades ES, Kales SN, Christoudias, SG, Tucker
    S, Liarokapis D, Christiani, DC. The Lipid
    Profile of Firefighters Over Time Opportunities
    for Prevention. J Occup Env Med 200244840-846.

53
  • Bibliography
  • Soteriades ES, Kales SN, Liarokapis D,
    Christiani, DC. Prospective Surveillance of
    Hypertension in Firefighters. J Clinical
    Hypertension 2003 5315-321.
  • Kales SN, Soteriades ES, Christoudias SG,
    Christiani DC. Firefighters and On-Duty Deaths
    from Coronary Heart Disease a Case Control
    Study. Environmental Health A Global Access
    Science Source 2003, 214.
  • Soteriades ES, Hauser R, Kawachi I, Liarokapis D,
    Christiani DC, Kales SN. Obesity and
    Cardiovascular Disease Risk Factors in
    Firefighters A Prospective Cohort Study. Obesity
    Research 200513 1756-1763.
  • Holder JD, Stalling L, Peeples L, Burress JW,
    Kales SN. Firefighter Heart Presumption
    Retirements in Massachusetts 1997-2004. J Occup
    Environ Med. 2006 481047-1053.
  • Kales SN, Soteriades ES, Christouphi CA,
    Christiani DC. Emergency Duties and Deaths from
    Heart Disease among Firefighters in the United
    States. N Engl J Med 20073561207-1215.
  • Mbanu I, Wellenius GA, Mittleman MA, Peeples L,
    Stallings LA, Kales SN. Seasonality and Coronary
    Heart Disease Deaths in United States
    Firefighters. Chronobiol Int. 2007 24 715726.
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