AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 52:261–269 (2009) Prevalence and Risk of Asthma Symptoms Among Firefighters in São Paulo, Brazil: A Population-Based Study Marcos Ribeiro, MD ,1
Ubiratan de Paula Santos, MD,1 Marco Antonio Bussacos,2 and Mario Terra-Filho, MD1 The firefighters are at increased risk of respiratory disease as a result of exposure to smoke and dust. The aim of this study was to determine the prevalence and risk associated with respiratory symptoms among city firefighters in São Paulo, Brazil. Methods A cross-sectional study utilizing the European Community Respiratory Health Survey (ECRHS) questionnaire was administered to firefighters and police officers, in order to evaluate their respiratory symptoms. Results Complete respiratory data were obtained from 1,235 firefighters and 1,839 police officers. Among the firefighters, there were 55.5% never-smokers, 22.4% current smokers and 18.2% former smokers (P < 0.05). Among the police officers, there were 63.4%, 18.6%, and 9.6% who were never-smokers, current smokers and former smokers (P < 0.05), respectively. Compared to police, firefighters experienced an increase in wheezing [OR ¼ 1.63 (95% CI: 1.43–1.87)], wheezing with breathlessness [OR ¼ 1.34 (95% CI: 1.10–1.64)], wheezing without a cold [OR ¼ 1.60 (95% CI: 1.32–1.95)], waking with tightness in the chest [OR ¼ 1.20 (95% CI: 1.02–1.42)], and rhinitis [OR ¼ 1.12 (95% CI: 1.03–1.22)]. The prevalence of adult-onset asthma in never-smokers was 9.3% and 6.7% for firefighters and police officers [OR ¼ 1.23 (95% CI: 1.01–1.56)]. An independent association was observed between years employed, smoking, history of rhinitis, and work as a firefighter and respiratory and nasal symptoms. We observed a high prevalence of asthma-like symptoms in firefighters who presented respiratory symptoms beginning immediately after firefighting. Conclusion These results suggest that the prevalence of respiratory symptoms and asthma in firefighters is higher than those in police officers. Work-as a firefighter, rhinitis and years employed were risk factors for respiratory symptoms of asthma. Am. J. Ind. Med. 52:261– 269, 2009. ß 2008 Wiley-Liss, Inc. KEY WORDS: asthma; firefighters; epidemiology; ECRHS questionnaire; occupational asthma INTRODUCTION 1 Occupational and Environmental Group, Pulmonary Division, Heart Institute (InCor), University of Sa‹o Paulo Medical School, Sa‹ o Paulo, Brazil 2 Division of Statistics and Epidemiology, Fundacentro, Sa‹ o Paulo, Brazil Contract grant sponsor: Pulmonary Division, Heart Institute (InCor), University of Sa‹ o Paulo Medical School, Sa‹o Paulo, Brazil. *Correspondence to: Dr. Marcos Ribeiro, Av. Angelica 382 ap 94, 01228-000 Sa‹ o Paulo, SP, Brazil. E-mail: marcospneumo@ig.com.br Accepted 3 November 2008 DOI 10.1002/ajim.20669. Published online in Wiley InterScience (www.interscience.wiley.com)
2008 Wiley-Liss, Inc. Firefighting ranks as one of the most dangerous occupations in the United States [Walton et al., 2003; Feldman et al., 2004]. The magnitude of the workforce is considerable, and in Sao Paulo, the largest cities in Brazil and in South America, there are over 2,500 firefighters. The city has 11 million inhabitants, an area of 1,500 km2, and each year about 9,000 fires and 200 dangerous cargo accidents occur. 262 Ribeiro et al. Asthma is the most common occupational respiratory lung disease in industrialized countries as reported from Canada [Liss et al., 1999], the United States [Matte et al., 1990], and the United Kingdom [Ross et al., 1998]. Some of these exposures have been assessed in epidemiological studies, yet few studies have assessed occupational asthma in the general population [Tielemans et al., 1999; Tarlo et al., 2000; Kogevinas et al., 2007]. Studies based on a small sample of firefighters demonstrated a high risk of disease in this population [Fosbroke et al., 1997; Liao et al., 2001]. We neither know relatively little on how individual factors influence firefighters’ respiratory injuries nor are we clear on the prevalence of asthma in this population. We therefore carried out a cross-sectional study using the European Community Respiratory Health Survey (ECRHS) questionnaire [Burney et al., 1994] to determine the prevalence of asthma-related respiratory symptoms in a population of firefighters from the Sao Paulo State Fire Department and compared these data with the results from a group of police officers from the same city. thermal barrier). Firefighters breathed air via self-contained breathing apparatus (SCBA). The decision to wear the SCBA and to have the facepiece on depended on the type of emergency the firefighters were responding to and whether they were following the standard protocols. There is limited information about the SCBA function during active firefighting. Through their command sections we provided boxes for questionnaire retrieval. All individuals that were identified as being eligible for the study were sent this questionnaire with a cover letter explaining the purpose of the study and its usefulness; they were advised that the Institutional Review Board granted approval to conduct the research, and they were informed that the questionnaire was anonymous with a discussion on confidentiality. The cover letter focused on general respiratory health and not on asthma. We conducted a second mailing in 3 weeks later to nonrespondents with another reminder card 2 weeks after that. This questionnaire was sent during the same season in the year and we were uninformed about the identities of the respondents. STUDY POPULATION AND METHODS A descriptive cross-sectional study was conducted in firefighters and police officers in São Paulo, Brazil. The Institutional Review Board of the Ethics in Research Committee of the University of São Paulo Medical School approved the study protocol, and patients gave written informed consent. Study Population The study population was a selection of full-time professional employees, no administrative personnel of the Fire Department or Department of Police were included. In 2001 firefighters and police officers were recruited from the São Paulo State Fire Department and the Department of Police of Sao Paulo City. In São Paulo city, 2,500 firefighters are distributed in four regional battalions, and 4,000 police officers are distributed in five regional sections. Questionnaires were distributed through their regional command structure to all firefighters (2,200) and police officers (3,000) who were on duty during 1 week. The firefighters were involved in different types of jobs during their work shift (including driving and firefighting) so they were all exposed to similar unfavorable conditions during firefighting activities. Each firefighter attended a mean of 38 fires per year; these rates were stable over the last 5 years. Firefighters carried a standard firefighter protective ensemble, which included helmet, hood and gloves, coat and bunker pants, and leather or rubber boots, depending on firefighter’s personal preference. Coat and bunker pants are composite materials (i.e., outer shell, moisture barrier, and Questionnaire A self-administered Brazilian-Portuguese translated and validated version [Ribeiro et al., 2007] of the European Community Respiratory Health Survey (ECRHS) questionnaire [Burney et al., 1994] was completed (Appendix). Included in the survey were supplemental questions, not part of the original ECRHS and developed specifically for the present study, which sought detailed information about work-related symptoms, smoking, occupational exposure to dust, fumes, and gases, and housing. Questions regarding the presence of these respiratory symptoms—wheezing, dyspnea, cough, and rhinitis—after firefighting fires and whether these symptoms persisted for more than 3 months were also included in the survey. Finally, information about medication use was requested. Patients were divided into ‘‘never-smokers,’’ ‘‘formersmokers,’’ and ‘‘current smokers’’ and to assess their level of smoking, the participants were asked about their regular use of cigarettes in the previous 12 months. Definition The definition of asthma was based on the ECRHS definition from the questionnaire alone. People with current asthma are defined as having one asthma attack in the last 12 months and/or current use of asthma medication [Burney et al., 1994] Adult-onset asthma, reported onset after starting practice as a firefighter or police officer was defined as meeting defined symptoms or as diagnosed by a physician. Prevalence of Asthma among Firefighters Statistical Analysis The demographic and clinical data are expressed as mean  SD. We did descriptive analyses and univariate analysis using a Student’s t-test, the chi-square test or Fisher’s exact test, and the Cochran–Mantzel–Haenzel test for risk estimative. Unconditional multiple logistic stepwise regression analysis was used to estimate the risk factors associated with respiratory symptoms. The evaluated independent variables were smoking, age, gender, years employed, rhinitis and work as a firefighter. The presence of rhinitis was used as a dependent and independent variable because this may reflect the exposition as well as be a cause associated with asthma symptoms. The statistical analysis was done using SAS 8.01 software (SAS Institute, Inc., Cary, NC). The minimum level of significance adopted was 0.05. RESULTS Questionnaires Returned Overall, 2,200 and 3,000 questionnaires were distributed to the firefighters and police officers, respectively. Responses from 3,635 individuals were completed and returned. Response rates were 1,480 (67%) for firefighters and 2,155 (72%) for police officers (P ¼ 0.86). Responders with incomplete answers (245 firefighters and 316 police officers) were excluded from the analysis. We restricted the analysis to the 1,235 (56%) firefighters and 1,839 (61%) police officers (P ¼ 0.76) that were still working at the time the questionnaire was distributed. It was not possible to send questionnaires to retired individuals. General Characteristics There were no significant differences in age between the groups. The study population comprised more men than women in both groups, mainly in firefighters (Table I). More than half of the subjects were never-smokers, and in the group of firefighters the number of current smokers and former smokers was higher than in the police officer group (P < 0.05). The firefighters had worked for a longer amount of time in their current jobs than the police officers had (P < 0.05) (Table I). 263 TABLE I. General Characteristics of the Study Population (n ¼ 3,074) Gender Male Female Age,years=mean (SD) Years employed, mean (SD) Smoking condition Never-smokers Former smokers Current smokers Without information Firefighters (n ¼1,235) Police officers (n ¼1,839) 1,189 (96.3%) 46 (3.7%) 33 (6.1) 11.5 (6.0)* 1,279 (69.5%) 560 (30.5%) 32 (6.6) 5.9 (5.2) 685 (55.5%) 225 (18.2%)* 277 (22.4%)* 48 (3.9%) 1166 (63.4%) 176 (9.6%) 342 (18.6%) 155 (8.4%) SD, standard deviation. *P < 0.05. waking with tightness in the chest, and rhinitis in firefighters were significantly higher than those observed in police officers. The diagnosis of asthma was present in 8.7% of firefighters and in 7.2% of police officers [OR, 95% CI: 1.21 (0.94–1.54)]. Figures 1–3 present the comparison of asthma symptoms among never-smokers and current smokers in male firefighters and police officers. The male firefighters who were never-smokers had a higher prevalence for eight of nine positive answers (OR, 95% CI): wheezing [1.91 (1.52– 2.40)], wheezing with breathlessness [1.58 (1.13–2.22)], wheezing without a cold [1.77 (1.25–2.52)], waking with tightness in the chest [1.67 (1.25–2.22)], waking with breathlessness [1.55 (1.14–2.12)], waking with cough [1.53 (1.18–1.97)], asthma attack [1.58 (1.00–2.51)] and rhinitis [1.36 (1.20–1.54)]; and were significantly higher (P < 0.05) than those in male police officers that were neversmokers (Figs. 1 and 2). In male firefighters who were current smokers, the prevalence was higher in only three out of nine positive answers: wheezing [1.55 (1.20–2.01)], waking with tightness in the chest [1.67 (1.17–2.40)] and rhinitis [1.40 (1.13– 1.75)] when compared with male police officers that were current-smokers (Figs. 1 and 3). Meanwhile, the estimated risk for symptoms was, in general, significantly higher in male smokers than in male firefighters that were neversmokers. The diagnosis of asthma in this group was presented in 9.3% of firefighters and in 6.7% of police officers [OR, 95% CI: 1.23 (1.01–1.56)]. Respiratory Symptoms Risk Factors The prevalence of positive answers from firefighters and police officers and the respective odds ratios are shown in Table II. The prevalence of symptoms such as wheezing, wheezing with breathlessness, wheezing without a cold, In a multiple logistic regression, the only independent risk factors in the development of asthma symptoms were years employed, smoking, rhinitis, and work as a 264 Ribeiro et al. TABLE II. Prevalence and OR of Respiratory Symptoms Among FirefightersVersus Police Questions Q1: Wheezing Q2: Wheezing with breathlessness Q3: Wheezing without a cold Q4:Wakingwithtightnessin the chest Q5: Waking with breathlessness Q6: Waking with cough Q7: Asthma attack Q8: Rhinitis Q9: Treatment for asthma Diagnosis of asthmaa Firefighters (n ¼1,235) (%) ‰ 30.9 13.2* 14.7‰ 17.4* 14.0 19.0 5.1 44.5* 7.0 8.7 Police officer (n ¼1,839) (%) OR (95% CI) 17.4 9.8 9.2 14.5 12.6 17.8 4.7 39.6 6.5 7.2 1.63 (1.43^1.87) 1.34 (1.10^1.64) 1.60 (1.32^1.95) 1.20 (1.02^1.42) 1.12 (0.93^1.34) 1.06 (0.92^1.24) 1.22 (0.88^1.68) 1.12 (1.03^1.22) 1.14 (0.87^1.50) 1.21 (0.94^1.54) OR, odds ratio; CI, confidence interval. a Diagnosis of asthma: asthma attack or treatment for asthma. *P < 0.05. ‰ P < 0.0001. firefighter. These risk factors were also associated with a high prevalence of positive answers. Age and gender were not associated with any of the questions. Table III shows the results and the respective odds ratio for respiratory symptoms in both groups. Rhinitis was an important risk factor related to all questions, and as a dependent variable it was associated with the firefighter job (Table III). Work as a firefighter was associated with a high risk of having symptoms; it doubled the risk of having wheezing and increased the use of asthma medications sevenfold. Reactive Airway Syndrome Disease (RADS) For the questions regarding RADS and the presence of wheezing, dyspnea, and coughing immediately after firefighting, 372 (30%) firefighters answered affirmatively. FIGURE 1. Prevalence of respiratory symptoms among male never-smokers and current smokers in the12 months preceding the survey.*P < 0.005; #P < 0.0001.Q1:Wheezing;Q2:Wheezingwith breathlessness; Q3:Wheezingwithout a cold;Q4:Wakingwithtightness in the chest; Q5: Waking with breathlessness; Q6: Waking with cough; Q7: Asthma attack; Q8: Rhinitis; Q9: Treatment for asthma; Asthma: Q7 þ Q9. [Color figure can be viewedin the onlineissue,which is available at www.interscience.wiley.com.] Prevalence of Asthma among Firefighters FIGURE 2. Oddsratioofrespiratorysymptomsamongmalenever-smokersinthe12monthsprecedingthesurvey.Q1:Wheezing;Q2: Wheezingwithbreathlessness; Q3:Wheezingwithouta cold;Q4:Wakingwithtightnessinthechest;Q5:Wakingwithbreathlessness; Q6: Wakingwith cough; Q7:Asthma attack; Q8:Rhinitis; Q9:Treatmentforasthma; Asthma:Q7 þ Q9. [Color figure canbeviewedinthe online issue,which is available at www.interscience.wiley.com.] FIGURE 3. Oddsratioofrespiratorysymptomsamongmalecurrentsmokersinthe12monthsprecedingthesurvey.Q1:Wheezing;Q2: Wheezingwithbreathlessness; Q3:Wheezingwithout a cold;Q4:Wakingwithtightnessinthe chest;Q5:Wakingwith breathlessness; Q6: Wakingwith cough; Q7:Asthma attack; Q8:Rhinitis; Q9:Treatment forasthma; Asthma: Q7 þ Q9. [Color figurecan beviewedinthe online issue,which is available at www.interscience.wiley.com.] 265 266 Ribeiro et al. TABLE III. Risk Factors Associated With Respiratory Symptoms From Multiple Logistic Regressions for Study Population OR (95% CI) Questions Years employed Smoking Rhinitis Work as a firefighter Q1: Wheezing Q2: Wheezing with breathlessness Q3: Wheezing without a cold Q4:Wakingwithtightnessin the chest Q5: Waking with breathlessness Q6: Waking with cough Q7: Asthma attack Q8: Rhinitis Q9: Treatment for asthma Diagnosis of asthmaa 1.44 (1.20^1.74) 1.32 (1.00^1.74) 1.29 (0.98^1.70) 1.61 (1.31^1.98) 1.74 (1.32^2.30) 1.26 (1.04^1.53) = 1.20 (1.00^1.45) = = 1.05 (1.03^1.07) = 1.04 (1.02^1.07) 1.03 (1.01^1.06) = 1.03 (1.01^1.05) = = = = 5.96 (4.72^7.56) 4.56 (3.18^6.74) 2.64 (1.87^3.77) 4.56 (3.50^5.97) 6.57 (4.81^9.11) 4.10 (3.23^5.24) 7.03 (4.99^13.27) = 7.94 (4.99^13.27) 6.57 (4.41^10.12) 2.20 (1.67^2.91) 1.81 (1.30^2.53) 3.69 (2.47^5.60) 1.25 (0.93^1.70) 2.82 (1.77^4.47) = = 1.35 (1.13^1.62) 7.89 (4.18^15.33) 1.25 (0.87^1.76) OR, odds ratio; CI, confidence interval. a Diagnosis of asthma: asthma attack or treatment for asthma. These symptoms persisted for more than 3 months in 11% (40 firefighters) or 3.2% of all subjects. DISCUSSION We examined the prevalence of respiratory and nasal symptoms among firefighters and police officers using the ECRHS questionnaire in a large population-based crosssectional study of adults in São Paulo City, Brazil. Our study demonstrates a moderate effect of hazardous environmental conditions on the respiratory system of the firefighters. In these subjects a high prevalence of respiratory symptoms were recorded for rhinitis, wheezing, waking with tightness in the chest, wheezing without a cold, and wheezing with breathlessness. The strengths of our study were in its relatively large sample group; a relatively good response rate; a similar response rate between the two groups; and in our ability to control possible confounders such as age and smoking. Our data show that the prevalence of adult asthma in never-smokers was 9.3% in firefighters and 6.7% in police officers [(OR, 95% CI: 1.23 (1.01–1.56)]. In the firefighters, an independent association was observed regarding the years employed, smoking, rhinitis, and respiratory symptoms that began immediately after firefighting and were associated with a higher prevalence of respiratory symptoms. These differences were more significant in the never-smoking firefighter group, suggesting an associated occupational factor. The multiple logistic regressions showed that having rhinitis, working as a firefighter and the number of years employed were the factors most strongly associated with a higher risk of having respiratory symptoms. The smoking condition showed a mild effect and it occurred in only four out of the nine questions in our questionnaire. The number of years employed is an influential factor that most likely reflects chronic and/or successive exposure; rhinitis is closely associated with asthma; and chronic cough and work as a firefighter showed a higher risk of symptoms for the majority of our questions. Prevalence of occupational asthma (OA) in an adult asthmatic population has varied in published studies and ranges from 6% to 17% depending on the definition used [Blanc et al., 1996; Nicholson et al., 2005; Kogevinas et al., 2007]. One of the major strengths of our study is that it is population-based, unlike other OA studies [Tielemans et al., 1999; Johnson et al., 2000]. We found a prevalence of work related asthma for 8.7% of firefighters in the population studied. There have been few prevalent studies of asthma and asthma-like symptoms among adult firefighters that use a standardized questionnaire [Rothman et al., 1991; Betchley et al., 1997; Mustajbegovic et al., 2001; Miedinger et al., 2007a,b] and none that use the ECRHS questionnaire exclusively. Some studies [Rothman et al., 1991; Betchley et al., 1997; Mustajbegovic et al., 2001] found an increase in one or more respiratory symptoms associated with recent fire-suppression activities. Others [Miedinger et al., 2007a,b] found that there was an increased risk of acute and chronic respiratory symptoms and obstructive airway changes in active firefighters. A number of possibilities could explain the high prevalence of respiratory and nasal symptoms despite the use of cartridge respirators. First, certain products of combustion, such as carbon monoxide, free radicals, or hot dry air, may not be effectively absorbed by the cartridges. An alternative hypothesis is that the use of cartridge respirators in a negative pressure mode could cause changes in the absence of chemical exposure. Another possibility is that there was variable compliance and variable effectiveness of use the respirators. Although the availability and effectiveness of protective devices such as SCBA [Guidotti and Prevalence of Asthma among Firefighters Clough, 1992] has increased, SCBA is insufficiently used by firefighters due to its weight and inconvenience [Burgess et al., 2001], especially when smoke is not visible and during phases of overhaul or work in the second line (drivers, pump manipulators), when important exposure to combustion products may persist. The appropriate equipment is often not used during the overhaul and clean-up phase after visible flames are extinguished despite the possible high concentration of combustion products even during this phase. The majority of symptoms reported by the firefighters in the present study were relatively mild complaints related to irritation of the respiratory tract. These findings are consistent with previous studies that have shown an increase in respiratory symptoms, including nasal irritation, cough, and sputum production and wheezing [Rothman et al., 1991; Betchley et al., 1997; Mustajbegovic et al., 2001; Miedinger et al., 2007a,b]. The clinical importance of this respiratory irritation may be minor in the present study population, which was comprised of health subjects with no underlying respiratory conditions. However, in ‘‘at-risk’’ subjects with conditions such as asthma and chronic obstructive pulmonary disease, this upper and lower respiratory tract irritation may be sufficient to exacerbate the lung condition. Differences in findings of the frequency and severity of respiratory problems among firefighters, also is probably the result of different methods used in the many studies, different populations studied (possibly sensitivity of the studied subjects), different types of smoke that firefighters are exposed to, as well as the frequency in the use of protective equipment. No information is available on facepiece fit for firefighters in Sao Paulo. It is possible that the extent of adverse health effects seen in Sao Paulo could be reduced if optimal facepiece fit were achieved. Duration of actual firefighting employment represents an improvement over total duration of employment as an index of exposure, but is still likely to be a poor surrogate for dose to specific agents. Firefighters vary in the number of fires they fight and exposures may vary greatly among fires. Employment information was ascertained from fire department records and without knowledge of disease outcome. Therefore, exposure misclassification resulting from the individual differences is likely to be no differential, which potentially resulted in an under-ascertainment of exposure effect. However, it is difficult to assess the magnitude of any potential bias without a better measure of exposure. An important strength of the investigation is our control group, the police officers. Both firefighters and police officers perform full-time work, and it is presumed that the police have a very limited or no exposure compared with firefighters, because they do not work in fire zones. Police officers and firefighters have similar demographic characteristics with respect to socioeconomic status, access to healthcare, retirement benefits, and physical entry require- 267 ments, and they have been used in epidemiological studies before [Kern et al., 1993; Burgess et al., 2003]. The São Paulo State Fire Department firefighter population is selected for physical fitness without respiratory pathology (which include a complete respiratory and cardiovascular examination), and also regular medical examination when in service to confirm the status ‘‘fit for duty.’’ It can be argued that although having asthma, these asthmatic firefighters are still in the active workforce and are therefore not suffering from a clinically relevant asthma. Fire Department is not allowed to perform challenge tests in asymptomatic candidates who have a negative respiratory history, due to the discriminatory impact of false-positive test results. The results seen in our study probably reflect, in part, the healthy worker effect. This is plausible because firefighters are generally very fit individuals, accustomed to high levels of exertion as well as selection factors within the fire department (company transfers, promotion, and retirement). Therefore, there is a possibility of under-reporting symptoms during medical screening of firefighters. Potential underreporting of symptoms and the current diagnosis of asthma have been reported in USA Air Force recruits [Nish and Schwietz, 1992]. The findings of the present study underline the value of performing objective questionnaires prior to enrolment and also during routine medical examination of firefighters. Seasonal as well as retired firefighters were not included in this study. Further studies are needed to evaluate the influence of asthma on the work performance of retired firefighters. It is important to perform periodic evaluations to identify asthma and rhinitis early among firefighters. A smoking cessation program should also be developed, especially among firefighters. The use of symptoms to identify workers who are potentially at a higher risk of pulmonary impairment has been recommended for asbestosexposed workers [Brodkin et al., 1993] and may be an efficient method of monitoring workers recently exposed to smoke when pulmonary function testing is unavailable. A reliable and validated standard respiratory questionnaire still needs to be developed for acute symptoms and could be useful for studies of firefighters. In conclusion, we observed that work as a firefighter is an independent risk of asthma and nasal symptoms. The next step is to perform a cohort study with the same or other control group. ACKNOWLEDGMENTS The authors would like to thank the São Paulo State Fire Department and the Department of Police of Sao Paulo City. Thanks also to the Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, 268 Ribeiro et al. Brazil and the Division of Statistics and Epidemiology, Fundacentro, São Paulo, Brazil. APPENDIX To answer the questions please choose the appropriate box. If you are unsure of the answer please choose ‘‘NO’’ 1. Have you had wheezing or whistling in your chest at any time in the last 12 months? IF ‘‘NO’’ GO TO QUESTION 2, IF ‘‘YES’’: 1.1. Have you been at all breathless when the wheezing noise was present? 1.2. Have you had this wheezing or whistling when you did not have a cold? 2. Have you woken up with a feeling of tightness in your chest at any time in the last 12 months? 3. Have you been woken by an attack of shortness of breath at any time in the last 12 months? Have you been woken by an attack of coughing at any time in the last 12 months? Have you had an attack of asthma in the last 12 months? Are you currently taking any medicine (including inhalers, aerosols or tablets) for asthma? Do you have any nasal allergies including hay fever? What is your date of birth? What is today’s date? Are you male or female? 4. 5. 6. 7. 8. 9. 10. REFERENCES Betchley C, Koenig JQ, van Belle G, Checkoway H, Reinhardt T. 1997. Pulmonary function and respiratory symptoms in forest firefighters. Am J Ind Med 31:503–509. Blanc PD, Cisternas M, Smith S, Yelin E. 1996. Occupational asthma in a community-based survey of adult asthma. Chest 109: 56S–57S. Brodkin CA, Barnhart S, Anderson G, Checkoway H, Omenn GS, Rosenstock L. 1993. Correlation between respiratory symptoms and pulmonary function in asbestos-exposed workers. Am Rev Respir Dis 148:32–37. Burgess JL, Nanson CJ, Bolstad-Johnson DM, Gerkin R, Hysong TA, Lantz RC, Sherrill DL, Crutchfield CD, Quan SF, Bernard AM, Witten ML. 2001. Adverse respiratory effects following overhaul in firefighters. J Occup Environ Med 43:467–473. Burgess JL, Witten ML, Nanson CJ, Hysong TA, Sherrill DL, Quan SF, Gerkin R, Bernard AM. 2003. Serum pneumoproteins: A crosssectional comparison of firefighters and police. Am J Ind Med 44: 246–253. Burney PG, Luczynska C, Chinn S, Jarvis D. 1994. The European Community Respiratory Health Survey. Eur Respir J 7:954–960. Feldman DM, Baron SL, Bernard BP, Lushniak BD, Banauch G, Arcentales W, Kelly KJ, Prezant DJ. 2004. Symptoms, respirator use, and pulmonary function changes among New York City firefighters responding to the World Trade Center disaster. Chest 125:1256– 1264. Fosbroke DE, Kisner SM, Myers JR. 1997. Working lifetime risk of occupational fatal injury. Am J Ind Med 31:459–467. Guidotti TL, Clough VM. 1992. Occupational health concerns of firefighting. Annu Rev Public Health 13:151–171. Johnson AR, Dimich-Ward HD, Manfreda J, Becklake MR, Ernst P, Sears MR, Bowie DM, Sweet L, Chan-Yeung M. 2000. Occupational asthma in adults in six Canadian communities. Am J Respir Crit Care Med 162:2058–2062. Kern DG, Neill MA, Wrenn DS, Varone JC. 1993. Investigation of a unique time-space cluster of sarcoidosis in firefighters. Am Rev Respir Dis 148:974–980. Kogevinas M, Zock JP, Jarvis D, Kromhout H, Lillienberg L, Plana E, Radon K, Torén K, Alliksoo A, Benke G, Blanc PD, Dahlman-Hoglund A, D’Errico A, Héry M, Kennedy S, Kunzli N, Leynaert B, Mirabelli MC, Muniozguren N, Norbäck D, Olivieri M, Payo F, Villani S, van Sprundel M, Urrutia I, Wieslander G, Sunyer J, Antó JM. 2007. Exposure to substances in the workplace and new-onset asthma: An international prospective population-based study (ECRHS-II). Lancet 28:336–341. Liao H, Arvey RD, Butler RJ, Nutting SM. 2001. Correlates of work injury frequency and duration among firefighters. J Occup Health Psychol 6:229–242. Liss GM, Tarlo SM, Banks D, Yeung KS, Schweigert M. 1999. Preliminary report of mortality among workers compensated for workrelated asthma. Am J Ind Med 35:465–471. Matte TD, Hoffman RE, Rosenman KD, Stanburg M. 1990. Surveillance of occupational asthma under the SENSOR model. Chest 98: 173S–178S. Miedinger D, Chhajed PN, Tamm M, Stolz D, Surber C, Leuppi ID. 2007a. Diagnostic tests for asthma in firefighters. Chest 131:1760– 1767. Miedinger D, Chhajed PN, Stolz D, Gysin C, Wanzenried AB, Schindler C, Surber C, Bucher HC, Tamm M, Leuppi JD. 2007b. Respiratory symptoms, atopy and bronchial hyperreactivity in professional firefighters. Eur Respir J 30:538–544. Mustajbegovic J, Zuskin E, Schachter EN, Kern J, Vrcic-Keglevic M, Heimer S, Vitale K, Nada T. 2001. Respiratory function in active firelighters. Am J Ind Med 40:55–62. Nicholson PJ, Cullinan P, Newman Taylor AJ, Burge PS, Boyle C. 2005. Evidence based guidelines for the prevention, identification, and management of occupational asthma. Occup Environ Med 62:290– 299. Nish WA, Schwietz LA. 1992. Underdiagnosis of asthma in young adults presenting for USAF basic training. Ann Allergy 69:239– 242. Ribeiro M, Angelini L, Robles-Ribeiro PG, Stelmach R, Santos UdeP, Terra-Filho M. 2007. Validation of the Brazilian-Portuguese version of the European Community Respiratory Health Survey in asthma patients. J Asthma 44:371–375. Ross DJ, Keynes HL, McDonald JC. 1998. SWORD 97: Surveillance of work-related and occupational respiratory disease in the UK. Occup Med 48:481–485. Prevalence of Asthma among Firefighters Rothman N, Ford DP, Baser ME, Hansen JA, O’Toole T, Tockman MS, Strickland PT. 1991. Pulmonary function and respiratory symptoms in wildland firefighters. J Occup Med 33:1163–1167. Tarlo SM, Leung K, Broder I, Silverman F, Holness DL. 2000. Asthmatic subjects symptomatically worse at work: Prevalence and characterization among a general asthma clinic population. Chest 118: 1309–1314. 269 Tielemans E, Heederik D, Burdorf A, Virmeulen R, Veulemans H, Kromhout H, Kartog K. 1999. Assessment of occupational exposures in a general population: Comparison of different methods. Occup Environ Med 56:145–151. Walton SM, Conrad KM, Furner SE, Samo DG. 2003. Cause, type, and workers’ compensation costs of injury to fire fighters. Am J Ind Med 43:454–458.