business problem research

6

MMG517: RESEARCH FOR MANAGERS

PFAS Chemicals: A Health Risk for Firefighters

Laura Coipel

12/13/20

Problem Statement

People think that the most significant cancer threat to firefighters are the products of combustion from the fires they fight. It is no surprise that since the 1970s, the risks involving fighting fires--injuries and death--were “accepted as an unavoidable occupational hazard” (FEMA, 2015, p. 5). In 1987, the National Fire Protection Association (NFPA) finally developed health and safety standards (NFPA, 2020).

Although culture and tradition run deep within the fire service and change can be difficult, research and science have made progress in safety standards for firefighters' well-being. At least that is what has been perceived. Somewhere between perception and reality is a more complicated truth. NFPA Standard 1971 suggests that in 1995 when turnout gear (fire protective clothing) by Morning Pride was issued to Cambridge firefighters, it was understood to be safer than the long rubber fire coats and three-quarter length boots of the past (NFPA, 2020).

In the fire service, the textiles for the turnout gear such as Nomex, Kevlar and Teflon were introduced by DuPont. Nomex and Kevlar are lightweight, strong, synthetic fibers in turnout gear that are flame and heat resistant. Another product, Aqueous Film-Forming Foam (AFFF), had been used by fire departments for fighting fuel fires. These products are made with chemicals that are not biodegradable; they are man-made and accumulate in individuals who are exposed over time, causing many negative health effects. Studies have identified health issues, such as thyroid problems, cancers, problems with the immune system, and even birth defects associated with the above chemicals (EPA, 2020). The Cambridge Fire Department stopped using AFFF in 2019 because it contained cancer-causing chemicals. The Cambridge Fire Department now uses Alcohol Resistant Aqueous Film-Forming Foam Concentrates (AR-AFFF), which combine fluoro-and hydrocarbon-surfactant vapor suppression for polar solvent and hydrocarbon fuel fires. However, the safety of this chemical agent is questionable and is still under study (Cotter, 2017).

In 1951, Dupont, a chemical manufacturing company, began to purchase perfluorooctanoic acid known as PFOA, or C8, from 3M, a technology giant (Rich, 2016). According to the United States Environmental Protection Agency (EPA), “Per- and polyfluoroalkyl substances (PFAS) are a group of man-made chemicals that includes PFOA, PFOS, GenX, and many other chemicals” (EPA, 2020, para 1). These PFAS chemicals have been shown to cause serious health effects. While some of the newer agents have a slightly different chemical construction, they have not been shown to be safe. DuPont and 3M knew PFAS was a problem in 1961 because internal secret medical studies were done. In the 1970s, DuPont discovered that there were high concentrations of PFOA in the blood of factory workers at their Washington Works facility (Rich, 2016).

Cancer rates among firefighters are still rising despite the use of Self-Contained Breathing Apparatus (SCBA) to protect them from products of combustion; in addition, firefighters are showering after fires and using specialized machines to clean their gear. According to Trowbridge et al. (2020), “Serum samples were collected and analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) to measure and compare PFAS levels between firefighters and office workers” (Environmental Science and Technology, 2020, p. 1). The results showed that PFAS levels were higher among the firefighters than they were among the office workers.

Research Question

How do PFAS chemicals in firefighting station uniforms, firefighting gear, and extinguishing agents effect the health of firefighters?

Dependent Variables – Health problems in firefighters

Independent Variables – early detection through biomonitoring

Independent Variables –finding and implementing safe chemical formulas

Independent Variables – heightened government regulations

Independent Variables – reducing exposer by changing station work uniforms

Independent Variables – reducing exposure by beginning clean cab practices

Theoretical Framework

Since the 1950s, when DuPont created Teflon, Nomex, and Kevlar, cancer rates have escalated significantly among firefighters. It was discovered that the NFPA, which was considered a credible agency for the protection of firefighters’ health and safety, relied on consultants rather than scientists for guidance as to the safety of these products. This resulted in the misconception that dangerous chemicals were being regulated and then contributed to the risks facing firefighters. The research focused on how turnout gear was supposed to be protective but instead contributed to cancer rates. In this research, the dependent variable was the elevated health risks for firefighters.

Early detection by fire departments for their members’ health using yearly specialized serum blood tests called biomonitoring, finding safe chemical formulas for AFFF and PPE, changing station uniforms to natural cotton, reducing exposure by implementing clean cab practices in apparatus as well as heightened government regulations, could help contribute to increased safety for firefighters. These independent variables would better serve firefighters than the government agencies that they now entrust with their lives. If the government enforced chemical regulations and penalized chemical companies, then companies would be held responsible for their products, and health risks among firefighters could be reduced.

Literature Review

There are many risks associated with firefighting, but the health of firefighters is the greatest and potentially most manageable risk. Cancer is the leading cause of death among firefighters and research is ongoing to find ways to reduce its frequency (National Institute for Occupational Safety and Health [NIOSH], 2018). The personal protective equipment (PPE), also known as turnout gear, that firefighters wear protects them from thermal, physical, and environmental hazards. The turnout gear has three layers: a thermal layer, a moisture barrier, and an outer shell. When DuPont introduced textiles such as Teflon, Nomex, and Kevlar, the National Fire Protection Agency (NFPA) raised the safety standards in the 1990s, to address the insufficient turnout gear that was still being worn at the time. Some departments thought that by going one step further and wearing uniforms (which are worn underneath the turnout gear) made from Nomex, they would add another layer of safety and lessen the possibility of burns. However, the turnout gear and the clothes are an additional health risk, elevating cancer rates among firefighters (Cotter, 2020).

The chemicals that DuPont uses in the textiles to make the turnout gear are man-made and accumulate in the environment and in the human body causing cancer over time (Cotter, 2020). Another class of products used by firefighters, also made from these chemicals, are Aqueous Film-Forming Foam Concentrates (AFFF). These products combine fluoro- and hydrocarbon-surfactant technologies to provide superior fire and vapor suppression for Class B, hydrocarbon fuel fires (Chemguard, 2020). But the more firefighters wear their gear and use AFFF, the greater their exposure to these chemicals which increases their susceptibility to cancer (Cotter, 2020).

3M had been making the chemical known as PFOA and using it to manufacture Teflon for four years when Dupont started purchasing PFOA from 3M in 1951. At the time, 3M advised Dupont to dispose of PFOA by incineration or by chemical-waste facilities (Rich, 2016). This implies that 3M was well aware of the toxicity levels of this product. Rich (2016) states that even DuPont had specified not to flush PFOA into water systems. In 1961 DuPont’s internal research showed the toxicity of PFOA (also known as C8) (Rich, 2016).

The challenge that fire departments have had is that the NFPA relies on manufacturers’ consultants for the data they use to set standards. Although they may be paid to have the answers, they are not scientists and they do not perform scientific studies (Cotter, 2017). This leads to inaccurate information that fire departments depend on. According to Cotter (2019), “In the case of 3M, [consultants] began sitting on NFPA 11, the committee for AFFF… as far back as 1972,” (para 5) and did not make the NFPA aware that these chemicals were hazardous. NFPA (2020) standards are global and every fire department, airport, and oil company still uses AFFF in a variety of forms. These standards were considered reliable. A decision-making process where manufacturers have a seat at the table and withhold information is misleading and inappropriate (Cotter, 2019).

DuPont was no longer able to keep their secret in 1999. A farmer in West Virginia was able to convince Attorney Rob Bilott from a large legal firm, Taft, a leader in the field of environmental law, to pursue his case. During June of 1999 Bilott filed a federal suit and after a year of investigation, DuPont settled for an undisclosed amount (Rich, 2016). Bilott proved to be

relentless, notifying every agency including the EPA, and John Ashcroft, the United States Attorney General. Bilott then filed a class-action suit “including more than 80,000 plaintiffs,” (Blake, 2020, para 69) that was instrumental in forcing the EPA to no longer ignore the looming blatant issue (Rich, 2016).

It was not until 2004 that DuPont was sued by the EPA and settled out of court for only $16.5 million. According to Kelly (2020), a single division [in DuPont] could profit more than [$16.5 million] in a single day. In an email dated February 16, 2006 from Susan Stalnecker, DuPont Vice President and Treasurer, to several people including Steve Johnson Administrator of the EPA posed a controversial request:

The ‘Ask’: In our opinion, the only voice that can cut through negative stories is the voice of EPA. We need the EPA to quickly (like first thing tomorrow) say the following:

1. Consumer products sold under the Teflon Brand are safe. These include…waterproof[ing]…among other products…

2. Further to date there are no harmful health effects known to be caused by PFOA. (Chemical Industry Document, 2006, p. 2)

Notably, after the EPA settlement in 2004, Dupont managed to negotiate a phase out of PFOA/C8 over 10 years by the year 2015. Based on this information, Dupont was asking the EPA to become complicit in Dupont dealings, to minimize the health threats in order to help DuPont’s bottom line.

Due to the slow reaction from the government agencies, Bilott persisted, and environmental scientists and other professionals took notice responding with the creation of the Madrid Statement in 2015 which called on the international community to work together to limit the production and use of PFAS chemicals. This document represented 200 professionals’ concerns and recommendations for Poly-Perfluoroalkyl substances. Particularly interesting in the Madrid Statement was the statement that “while some shorter-chain fluorinated alternatives seem to be less bio accumulative, they are still as environmentally persistent… or have persistent degradation products. …A switch to short-chain and other fluorinated alternatives may not reduce the amounts of PFASs in the environment” (EHP, 2015, para 7).

Bilott began to make waves and the chemical manufacturing community-- DuPont, 3M, Honeywell and Gore among others--tried to maintain their economic hold. The health risks associated with firefighting had been overlooked for so long that firefighters and their families were forced to educate themselves. Diane Cotter, the wife a lieutenant on the Worcester, MA Fire department who was diagnosed with prostate cancer, wanted to put policies and regulations in place to protect firefighters. According to Cotter in 2016, the International Association of Firefighters (IAFF) were made aware of the findings of the European Chemical Agency, which found that: “PFOA and its ammonium salt (APFO) have been identified as substances of very high concern (SVHC) under REACH by unanimous agreement between EU Member States in July 2013” (ECHA, 2018, p. 8). This three-hundred-and-seventy-page document announced that Europe would be transitioning to non-PFOA PPE (Cotter, 2017). When Cotter did not get the response from the IAFF that she was hoping for she did not stop there, and a flurry of articles began to be published in trade magazines beginning in March of 2017. Numerous emails were sent by Cotter to every agency within the fire service and politicians alike. Then in January 2018 Cotter met Dr. Graham Peaslee.

Peaslee, Professor for Experimental Nuclear Physics at the University of Notre Dame, was asked by Cotter if he would test the turnout gear for safety. Peaslee accepted the proposal and mentioned that when his students were handling the material to test for PFAS they could measure levels of fluorine, which is a source of these chemicals, on their hands just from merely touching the cloth (Cotter, 2020). Several studies ensued which tested the material in the gear, and dust samples in storage areas of the gear, and proved that the material sheds PFAS chemicals. In addition, “Biomonitoring studies [on serum levels in the blood] …provide physicians and public health officials with reference values so that they can determine whether people have been exposed to higher levels of PFOA than are found in the general population” (CDC, 2017, para 6).

The blood serum study results proved that exposure to PFOA in the United States was widespread. Peaslee stated for every PFOA molecule, they found a hundred other per fluorinated molecules; the numbers multiplied by the hundreds raising his concern. Of all the molecules tested none were found safe (Cotter, 2013). During all this testing it was discovered that not only turnout gear, but many first-responder uniforms have been treated with PFAS to provide water resistance (Marr, 2018).

By this time government agencies and agencies associated with the fire service could no longer evade the truth. According to the IAFF in September 2018:

The EPA… engaged in reviews of safer substitutes for PFAS AFFF as part of the 2010/15 PFOA Stewardship Program and the New Chemical Program. One suitable substitute is an AFFF that contains certain fluorocarbon surfactants with fewer than six carbons (also referred to as C6 or fluorotelomer foam) made through telomerization. These foams do not form PFOA when they degrade and are generally less toxic and less persistent in the environment compared to the longer chain PFOA, although they are likely to contain trace amounts of PFOA as a byproduct of manufacturing. (Putnam Testimony, 2018, para. 18)

This research indicates that although the EPA is tasked with regulatory oversight, both their research and policies have been insufficient. The EPA has been made aware of the toxicity of PFOA, but the newer C6 formula, which the EPA has not studied or restricted, is not actually a safer solution. In a recent interview (Cotter, 2020), Peaslee expressed his concerns with the C6 formula. During his testing, he noted that C6, when exposed to the air or the bloodstream, oxidizes and turns into PFOA. Despite the fact that C6 will be banned in Europe, it is still being used today in American firefighters’ turnout gear. Thus, Peaslee’s research suggests that this alternative is not any safer, and government agencies and policies overlook the scientific evidence and protect manufacturers and lobbyists more than the firefighters who risk their lives protecting their communities (Cotter, 2020).

In the past few years, Congress has considered reform measures to update the Toxic Substances Control Act of 1976, passing bills through the Senate, while also urging the EPA to update its own chemical assessments to minimize unreasonable risks and harmful exposures (Kelly, 2016). Due to the lack of expediency by the federal government, states such as Massachusetts have taken regulatory measures of their own. Massachusetts took AFFF and older, PFAS-containing foams off the market, replacing them with C6, short-chain formulas used by fire departments (MassDEP, 2019). Although policies and regulations are currently being enacted, the interests of manufacturers are still better protected by patent laws than the lives of firefighters themselves. One proactive step fire departments can take would be regular screening for early detection of cancer by testing blood serum for high levels of PFOA and offering regular tests for firefighters using biomonitoring (CDC, 2013). By implementing a storage policy for contaminated gear on the truck, fire departments could reduce the exposure to toxins firefighters receive through their gear. Another way fire departments could ensure firefighter safety would be to use environmental agencies that promote green products and offer screening services for toxins in products, such as Green Screen (Green Science, 2020).

Although being a professional firefighter is inherently risky, firefighters face increased risk due to a lack of protection by governing authorities and agencies, such as the NFPA, CDC and EPA, which are supposed to ensure the health and safety of firefighters, but research has provided evidence that they have instead often protected the interests of manufacturing companies such as DuPont. DuPont and other manufacturers have continued to evade lawsuits and restrictions by splitting off into smaller companies. Together, lobbyists and policy makers have been slow to act to implement regulations that might have adverse economic impacts on these powerful manufacturing companies. In fact, many committee members overseeing the NFPA standards are manufacturing consultants, not scientists. This lack of government leadership has left distraught family members of firefighters to advocate for their sick family members’ health. Although reform measures have been introduced, chemical companies can use patent protections to further hide the toxicity of their products, thereby extending this dangerous cycle of misinformation and dishonesty. Until these companies are forced to produce safer products, in terms of both human and environmental health, cancer and other health risks will continue to climb.

Methodology

Research Design

The literature review shows that PFAS, bio-accumulative, and manmade chemicals are a substantial health concern for firefighters and the environment. Government regulations as well as policy changes need to be put in place to protect human lives. Laws to prevent chemical companies from hiding behind patent protections and splitting their companies to reduce legal payouts when companies are under scrutiny need to be implemented. The purpose of this research is to document Cambridge Fire Fighters’ understanding of PFAS chemicals in their uniforms and turnout gear, as well as to document their experience of health-related issues which have been associated with exposure to PFAS. A quantitative survey was designed to gauge participants responses. It was designed around two hypotheses:

· H1: The longer one works on the fire department, the more exposure one has to PFAS chemicals and its health effects.

· H2: Firefighters assume that their uniforms and gear have been designed to protect them from the hazards they face fighting fires.

Subjects

The survey population included 274 members of the Cambridge Fire Department. Of the 274 members, 52 members voluntarily completed and returned the surveys for statistical analyses. This represents a response rate of 19.7%. The sample consisted of 84.6% men, 13.6% women, and 1.9% people who preferred not to claim a gender. No one under the age of 25 responded. 3.8% are between the ages of 26-30. 38.5% were between the ages of 31-40. 21.2% were between the ages of 41- 50. 36.5% were 51 years or older. 7.7% had 5 years or less on the department. 25% had 6-10 years on the department. 13.5% had 11-15 years on the department. 15.4% had 16-20 years on the department. 23.1% had 21-25 years on the department. 15.4% had 26+ years on the department. 71.2% are Firefighters. 17.3% are Lieutenants. 7.7% are Captains. 3.8% are Deputy Chiefs or above.

Data Collection

A survey was designed based on the following variables. The dependent variable is health effects on firefighters. The independent variables are the length of time exposed to PFAS chemicals, and knowledge informs choices. For more information see the “instruments” section. This survey was administered to 274 firefighters in Cambridge. It was approved by the Chief of the Cambridge Fire Department and distributed through the union (Cambridge Fire Department, Local 30) via email with a survey link. Participants were told they had one week to answer.

Instruments

1.Your age

· 18 – 25

· 26 – 30

· 31- 40

· 41- 50

· 51+

2. Gender

· Male

· Female

· I prefer not to answer

3. Job Description

· Chief/Deputy

· Captain

· Lieutenant

· Firefighter

4. Time on the Job

· 0-5 years

· 6-10 years

· 11-15 years

· 16-20 years

· 25+ years

5. How important is your personal health to you?

· Very important

· Important

· Somewhat important

· Not important

6. How often do you visit your PCP?

· Every year

· A couple of times a year

· Several times during the year

· Every 2 – 3 years

· Never

7. Does your PCP initiate cancer screening?

· Yes

· No

8. Do you have to ask your PCP for cancer screening?

· Yes

· No

9. Do you know that your uniforms and turnout gear are made with Kevlar, Nomex, and Teflon?

· Yes

· No

· Maybe

10. What is the name brand of your gear?

· Globe

· Morning Pride

· Lion

· Other

11. Have you heard of PFAS chemicals before?

· Yes

· No

12. Would you be concerned about the material used in your gear if you were aware that it is treated with chemicals called PFAS?

· Strongly concerned

· Concerned

· Neutral

· Not concerned

· Strongly not concerned

13. Do you know that PFAS chemicals are bio-accumulative and accumulate in your blood over time?

· Yes

· No

· I do now

14. Would you like to learn more about PFAS?

· Very important to me

· Important to me

· Neutral

· Not very interested

· Not interested at all

15. Do you follow the policies for cleaning your gear?

· Yes

· No

· Maybe

16. I clean my gear.

· Always

· Often

· Sometimes

· Rarely

· Never

17. I take precautions after a fire by using wipes and showering.

· Always

· Often

· Sometimes

· Rarely

· Never

18. Do you know that these chemicals can cause thyroid problems, cancers, problems with the immune system, and even birth defects? (check all that apply)

· Yes

· I know they cause cancer

· I know they cause thyroid problems

· I know they cause problems with your immune system

· I know they cause birth defects

· No

19. Have you been diagnosed with thyroid problems, cancers, problems with the immune system, or had children with birth defects?

· Yes

· No

· Maybe

20. What have you been diagnosed with? (check all that apply)

· Thyroid problems

· Cancer

· Birth defects

· Immune problems

· None of the above

21. I have high blood pressure

· Yes

· No

· I don’t know

22. I have high cholesterol.

· Yes

· No

· I don’t know

Questions 1-4 were demographic. Questions 5-8 ask about how proactive firefighters are about their healthcare by comparing how often they visit the doctor, personally advocate for cancer screening, or have doctor-initiated cancer screening. Questions 9-10 ask what firefighters know about their PPE brands and the material used to make them. Questions 11-14 ask about PFAS chemicals to determine firefighters’ knowledge of them and interest in learning more. Questions 15-17 ask about cleaning of gear and what firefighters do post-exposure to minimize health risks. Question 18 asks if firefighters are aware of PFAS-related health problems. Questions 19-22 ask what health problems firefighters currently experience that can be attributed to PFAS chemicals.

Results

Table 1.

Table 2.

Table 3.

Analysis of Variance: Multiple-Effect Screening on Number of Diseases (Excluding Birth-defects)
Description	Effect	F-Ratio	P-Value
One-way ANOVA	Age	0.665	0.579
One-way ANOVA	Gender	0.010	0.921
One-way ANOVA	Time on Job	1.578	0.193
Interaction Effect	Age*Gender	2.321	0.113
Interaction Effect	Age*Time on Job	3.678	0.021*
Interaction Effect	Gender*Time on Job	2.030	0.147

Multiple effect screening found no significant effect of age, gender, or time on job on the number of diseases (p > .05). Additionally, no interaction effects were found between age/gender or gender/time on job (p > .05), while a single interaction effect between age/time on job was significant (p < .05).

Table 4.

Out of the six diseases/conditions screened for, the length of time on job had a significant effect on rates of cancer (p < .05), high-blood pressure (p < .01), and high cholesterol (p < .05). Birth-defects, immune disorders, and thyroid disease were not impacted by the length of time on the job (p > .05).

Table 5.

A single measurement of the extent of PFAS knowledge was generated by adding the sum of scores between questions 11), 13), and 18). One-way ANOVA indicated that the level of PFAS knowledge is not affected by the number of years worked on the job (p > .05).

Table 6.

Table 7.

Table 8.

Limitations

Out of 274 surveys sent out, only 52 responded. This is a small sample from which to draw significant conclusions. When preparing the survey in Google frames an oversight was made on question 20 by adding an option of “other” instead of adding “none of the above,” and making all questions mandatory to answer. An adjustment was made early on, however, some participants wrote in option “other” about how they could not answer that question properly. Another limitation was confusion on the part of the researcher on exactly what questions to ask to focus on the research question to apply the results more accurately.

Discussion

The results need to be interpreted with caution, because age can also play a role in the rates of occurrence of many diseases. As shown in table 3, age and the length of time are positively correlated. Therefore, it cannot be proven that the length of time/cumulative PSAF exposure alone is responsible for the increased rates of these conditions. The results of table 5 indicate that more education needs to be implemented for employees of the Cambridge Fire Department so that they can appreciate the impact of PFAS exposure and how it contributes to one’s health.

Conclusion

While the introduction of chemically altered textiles has reduced the dangers inherent in the act of firefighting, the Cambridge Fire Department has unknowingly exposed their members to PFAS chemicals in their uniforms and gear for the past 26+ years. Awareness of these chemical dangers, as highlighted by Diane Cotter and Graham Peaslee, have been recognized since 2017. However, cancer rates are still on the rise for firefighters. In addition, there is a lack of knowledge about PFAS chemicals department wide as noted in tables 5,6,7 and 8. The department should make every effort to reduce exposure by changing uniforms to materials that are natural like cotton. Educating employees about PFAS chemicals would enable employees to make informed decisions and take further precautions. Also, the department could reorganize the storage of the turnout gear in the fire apparatus (trucks) when it’s not in use in order to maintain a clean cab for the fire crew. To increase proactive health measures the department should offer yearly specialized serum blood tests (biomonitoring) to employees to establish the current levels of PFAS in their blood, and implement cancer screening if their PCP’s don’t offer it. The department should also work with employees on training and safety measures for the health and wellbeing of their members.

References

ACS Publications. (2020, February 26). Exposure to Perfluoroalkyl Substances in a Cohort of Women Firefighters and Office Workers in San Francisco. Environmental Science & Technology. https://pubs.acs.org/doi/abs/10.1021/acs.est.9b05490

Basic Information on PFAS. (2018, December 06). Retrieved December 11, 2020, from https://www.epa.gov/pfas/basic-information-pfas

Blake, M., (2020). A toxic chemical ruined the lives of these people — and it’s probably in your blood. The Huffington Post. Retrieved from: https://highline.huffingtonpost.com/articles/en/welcome-to-beautiful-parkersburg/

Blum, A., Balan, S., Scheringer, M., Trier, X., Goldenman, G., Cousins, I., . . . Weber, R. (2015, May). The Madrid Statement on Poly- and Perfluoroalkyl Substances (PFASs). Retrieved December 11, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4421777/

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Cotter, D. (2020, October 13). Transcript of October 11, 2020 Dr. Graham Peaslee interview with AFSO21LLC’s Kevin Ferrara [Audio podcast]. https://dianecotter.medium.com/transcript-of-october-11-2020-dr-graham-peaslee-interview-with-afso21llcs-kevin-ferrara-4b918694a3e7

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https://www.greenscreenchemicals.org/resources/entry/fff-press-release

Industrydocuments.ucsf.edu. (2020). Industry Documents Library. Retrieved from: https://www.industrydocuments.ucsf.edu/chemical/docs/

Kelly, S. (2016). Teflon's toxic legacy: for more than half a century DuPont hid information that a chemical it was using to make Teflon might be making people sick. Gale – Institution Finder. Retrieved from: https://go.gale.com/ps/

Mass.gov. (2019). Statewide Program Eradicates Nearly 150,000 Pounds of Toxic Firefighting Foam to Ensure Public Health. Retrieved from: https://www.mass.gov/news/statewide-program-eradicates-nearly-150000-pounds-of-toxic-firefighting-foam-to-ensure-public

Medium. (2020). We Have Been Led to Believe Our Toxic Exposures Start at The Doors of a Fire. That Is A Lie. Retrieved from: https://dianecotter.medium.com/we-have-been-led-to-believe-our-toxic-exposures-start-at-the-doors-of-a-fire-that-is-a-lie

National Fire Protection Agency. (2020). https://nfpa.org/standard_items/search_results?searchStr=1971

Perfluorooctanoic Acid. (PFOA). 2017, April 7). Factsheet. Centers for Disease Control and Prevention, Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/biomonitoring/PFOA_FactSheet.html

Putnam Testimony. (2018, September 26). International Association of Fire Fighters Statement of Lieutenant Timothy Putnam, Vice-president, Tidewater Federal Fire Fighters before the Subcommittee on Federal Spending Oversight & Emergency Management United States Senate on the federal role in the toxic pfas chemical crisis. Retrieved from

https://www.hsgac.senate.gov/imo/media/doc/Putnam%20Testimony.pdf

Rich, N. (2016, January 6). The lawyer who became DuPont’s worst nightmare, New York Times . Retrieved from https://www.nytimes.com/2016/01/10/magazine/the-lawyer-who-became-duponts-worst-nightmare.html

Station Pride. (2020). Notre Dame University pushes the modern fire service to be better. Retrieved from: https://station-pride.com/2019/10/21/notre-dame-university-pushes-the-modern-fire-service-to-be-better/

Station Pride. (2020). The real cancer in your gear. Retrieved from: https://station-pride.com/2017/03/28/the-real-cancer-in-your-gear/