Latest / Firefighter Nation Podcast / Firefighter Breast Milk: Do I Need to Pump and Dump?
Transcript
- Nat Kapustin: Dr. Alicia Jung is an epidemiologist with a background in occupational exposures and health, reproductive health and epigenetics. She graduated and received training from the University of Arizona, where she focused on studying women's reproductive health and biomarkers of exposure among firefighters. She currently works as a senior scientist for Exponent Inc., a scientific and engineering consulting company working on projects including the human health effects of air pollution. Trends and risk factors in cancer incidents and examining exposures and mortality in occupational worker studies. Yeah, Rachel, I am so sorry that I was not able to join you for this episode, but this is something that really hits close to home for me. I I had two kids. And not to get two graphic fill listeners involved, when you have two kids, you gotta feed two kids, right? And that was always such a question to me as a A brand new mom already worried that I had exposed the kids in utero. being a mom comes with all kinds of stress. And then you have to wonder about your the food supply, which you're feeding your children from, you know, the exposures that you go on on EMS calls on any has that incident, and then on fire scenes. And something that was really fascinating that you and I were talking about is even though the study was done. The study is going to be anything to do with firefighters is always gonna be dependent on well, what part of the country did you pull this sample from? are they from fire departments that ran fires every day? Were they from fire departments that maybe ran a fire a week or a fire a month? It's the fascination, the fascinating thing that is science and exposures and being a mom. It is so unique and so understudied, which is why I was so excited that you were able to do this episode with her. Yeah, it was a great conversation, Steph, and I'm sorry you weren't there. But hopefully this episode will offer anyone who's interested some clarity on this really important topic. And here's our conversation with Dr. Jung. So, Dr. Jung, thank you so much for joining us today. I'm really glad to be talking with you. Yes, thanks for having me. I'm really excited. I wanna start just by getting a real understanding. A little bit for myself, but also for our audience, about the research that you've done in this space. What just tell us about the work that you've done before we dive into all of our questions? For for me, my involvement working with firefighters, being involved in firefighter research began back in graduate school when I was attending the University of Arizona. And I first started working under and being mentored by Dr. Jeff Burgess. Who was able to involve me in a lot of like really interesting projects in the fire service, including examining emergency service vehicle incidents as well as evaluating occupational exposures among structural firefighters and the impact of potential interventions to try to reduce the exposures. Then during my graduate research, I just I realized that what I was really interested in was learning more about women firefighters and it was it didn't take long to realize that w there wasn't much known about women firefighters at the time. So I was very lucky and fortunate enough to be able to collaborate with Dr. Sarah Janke of NDRI USA and I was able to utilize survey data from one of her large surveys of women firefighters and able to base my whole dissertation on adverse reproductive outcomes among women firefighters in the US Specifically focusing on the prevalence and the risk factors associated with miscarriages, preterm births, and self-reported infertility. From there, I was able to expand that to looking at I guess what we'll be talking about later on, which is the excretion of polybrominated diphenyl ethers or PBDEs, and AHR activation, which is a measure of toxicity. in the breast milk of firefighters. That's great. And I mean round it rounding it out, which is non-reproductive related, but what I still find relatively interesting is epigenetic biomarkers, such as DNA methylation or microRNA as potential markers of occupational exposure in firefighters. Which is a little more like technical and nerdy, but you know, still interesting because epigenetic markers have been linked with health status, disease risk, and biological aging. So we love scientific and nerdy. so can you can you explain a little bit more about what an epigenetic marker is? Yeah. I guess plainly epigenetic biomarkers, they are reversible molecular changes that can regulate gene activity or turn genes on and off. without actually affecting your underlying DNA sequence. So they're able to respond by turning on and off dynamically to environmental factors, including like I mean the big one we are thinking about is toxins, but also your diet, stress and like maybe even like air pollution. So thank you for that. so and now I we're kind of ta this is a little bit of a tangent, but so is is the idea that these could be in breast milk of a firefighter after they've responded to an incident. In in the context of firefighter research, what we have been able to demonstrate is that we've been able to measure these like significant differences in new recruits when we compare their these measures from when they started. So before when when they're still in training versus two years into their careers. And even and also like groups of like wildland urban interface firefighters before and after a wildland fire season. So, you know, we're able to see these changes happening in like relative a relatively short amount of time, you know, like within a year or two years. And the hope is that if we can if we can see these changes happening during their career, we can also if we can create interventions to reduce effective interventions to reduce occupational exposures, we could kind of track these measures and see a related decrease in these epigenetic changes as a sign of like an effective intervention. Got it. Okay. Thank you for that. And I know this was that was kind of off topic, but since you started talking about it, it sounded interesting and I just wanted to get a little bit more yeah. And there's there's a there's a there's a lot more going on in this space as well. Yeah. So there's I'm sure there's other researchers that can do a more thorough job of explaining it. But this is just like, you know, just giving you the basics of what what it is, what we can see. Yeah, no, and thank you. So coming back to the the the research on breast milk, tell us about that research, you know, what you've done in this space and what you were really looking to learn. The main goal of the project was to examine if Firefighting exposures and for this the po the the purpose of this study it was responding to fire events and categorized as either interior or exterior fires. Seeing if those firefighting exposures could increase the concentration of PBDEs and AHR activation. AHR is aeryl hydrocarbon receptor. I'm not sure if I explained that before. But it's a measure it's a measure of toxicity. It's created breast milk. So we ended up recruiting a sample sample of twenty one active duty breastfeeding firefighters and ten controls. The the controls were non-firefighters that were actually recruited by the participating firefighters. So we refer to them as like non-firefighting friends. We were able to have these the firefighter participants provide samples of breast milk before fire incidents as well as increments preceding the post-fire event up to 72 hours. And the goal was this it's was of compare the firefighter levels in the firefighters with an with the controls, as well as look to see if we can measure any differences or or trends in PBDEs and AHR activation over time after responding to the fire. So when you say over time, and and correct me if I'm wrong, but I think what I saw is that It was up to seventy-two hours, but it was actually in much smaller increments, right? two hours, four hours, or I don't know what the smallest increment was, but it was every few hours following the fire. Yeah, it was it was a lot of work. it was, you know, there was a baseline event which we consider where we considered them non exposed to fire exposures. and then two hours post event eight, twenty four, forty eight, seventy two. Yeah. Wow. And so so an individual participant had to provide a sample from each of those increments. Yes. Wow. Yes. Without giving away your findings, which we'll get to. What was the concern? What were you saying? Like we want to see if this is what we find in like, you know, the most kind of basic terms. At the time, there wasn't really specific guidance on like or or specific workplace modifications that were recommended or suggested for these breastfeeding active duty firefighters. You know, I think I think it was it was simply that they should avoid unprotected exposure to toxic concentrations. But it didn't it it wasn't able these guidelines or they weren't able to provide additional specific examples of what they should be doing instead. And, you know, with the importance and significance of like the the health benefits of being able to breastfeed your child or at least provide them like pumped breast milk. The concern was that that these women had was that am I are any of the workplace exposures I'm experiencing being being passed through my breast milk to my child. Mm-hmm. what should I be doing? Should I be, quote unquote pump and dumping the breast milk? Like to what extent do I need to do that? Yeah. Or is it is it still safe to provide them with breast milk? And and these were concerns that were brought directly to our researchers by firefighters. Mm-hmm. So we what we really wanted to do was to try and provide evidence that could inform recommendations about either the the necessity or the timing of pumping breast milk for working firefighters and be able and I think this is a great example of a lot of the research that the firefighting community inspires us to do. Because these are actual questions and needs that are communicated to us. Yeah. You know, and I I I don't know if we would have been able if we would have come up with the same question at the same time if it wasn't first, you know, brought to us. But I mean like s scientifically the concern is that a lot of the toxins that you can that could be that you're potenti potentially exposed to on the job could accumulate in the tissues where like your breast milk is produced and could then be excreted through your breast milk. Right. And I think the the research surrounding PBDEs detected in breast milk is rather mixed. But we know from just general comparisons of firefighters to non-firefighting populations that at least in serum or blood samples, that firefighters tend to have elevated levels of PBDEs, among other toxins of concern, compared to non firefighters. And what does that what are the implications of that? What does that lead to? So I think the the main like health concerns for PBDEs to Children who are prenatally exposed are relate to neurodevelopment behavior. some studies have also reported associations with cognitive or intelligence deficits. Though of course these are these are in different populations where and through different populations that aren't accounting for firefighters specifically. That's super helpful though, because I have to tell you, from my initial question, and maybe this is just my own, you know, need to learn, which is why we're here, I assumed this was just about cancer prevention. Right. But it's it's not necessarily. so that's you know, I I feel like, you know, it's for a long time, and this is, you know, well justified, the spotlight has been on cancer risk. Yeah. Cancer effects in firefighters because at least in the recent recent years, it's the one that's been the most notable. Yeah. The most notable. So it's it's gotten a lot of like a attention from media, from researchers, from support networks and support groups. Mm-hmm. And it's well justified. But, you know, there's a there's like a breadth of research that remains insufficiently explored. Although I feel like we're we're certainly starting to get there. so there's a plenty of opportunity for, you know, more research ideas, more funding, more projects that explore some of these like underexplored topics. Yeah. Well, and I think it's an interesting question of it's a little bit of like the chicken or the egg, like, you know, is it that there is a a condition or illness or, you know, whatever it may be? And then it's like backing into it, like, well. Do any of the factors or exposures that you know happen for firefighters responding to an incident, do any of those lead to this condition? And then the flip side is like, here's the situation that these firefighters in, what does it lead to? So it's like, are you starting with like, you know, what they're exposed to and then what they find themselves, you know, having to deal with on the medical front, or is it the reverse of that? You know? Yeah. So it is that that's really interesting. So tell us about your findings. In our study where we were able to recruit, and I I I believe some of our participants helped us recruit other participants, right? We did not find actually any significant differences in the levels of PBDEs and firefighters compared to controls. Neither did we see any significant changes in PBDEs or AHR response among firefighters over time. And we did also because the sample was smaller, we were able to also look at each of the each individual's samples individually. And we weren't able to really see any consistent trends that would support an overall pattern of an of association. So at least in this in this study, the results did not support foregoing breastfeeding after a fire response. However, it's balancing work and life, especially as a new mother, is an intensely personal. experience. And I mean I I I feel even though our results did not support pump and dumping, this is this is probably something that every person should consider individually and make a personal choice about and what they would consider what they would feel comfortable doing. Especially, you know, if it involves their child. That and that is actually something I I wanted to ask you about and you you just answered it because I wanna and I'd love to talk a little bit more about it. You know, there is this question Just, but do you feel great about it? Right. Like so we know that the research didn't necessarily raise any huge red flags, which doesn't mean that there isn't maybe more to learn. But then also, I and I was gonna very specifically ask you: would you w recommend a pump and dump approach, even knowing that your results didn't necessarily suggest that that's necessary? Yeah. So I will I will have Provide more context for the results in the study is that sure there were limitations to the study that people who are trying to interpret the results should consider. And every study that is performed has limitations, has weaknesses. And if you if you come across a paper that says doesn't have this, then you should probably question the quality of the work of the that the these scientists are performing. But in our case, we had a relatively small number of women. This in terms of women firefighters and fire women firefighter research, this is a monumental number of of participants. We were able to find and recruit within a similar time period and were able to commit to helping us helping provide these samples and shipping them to us to be analyzed, right? But Because of that number, we were limited to being able to detect changes in the sum of the PBDEs in these samples. We could we would only be able to detect as a significant difference if the if it had increased by a factor of one point five, right? So a fifty percent increase. Okay. And on a related note, we were we were only really powered to detect an increase in AHR response or the toxicity measure. By a factor of one point four or about a forty percent increase. Okay. So from our results, we can say that any occupational exposures these women had, if they didn't experience anything that would have increased their PBDEE levels or HR response by a factor of one point five or one point four, respectively. So, you know, the the PPE they had, the training they had they received, the protocols they were engaging with, they were effective, we can say to that point. However, we weren't Really we can't really say that they didn't experience significant changes below those levels. Right. So it could have been a 30% increase, which would be perhaps concerning, but it didn't necessarily identify that. Yes. And you know, we can't really we can't really say anything about it beyond that. Right. And I mean there's also areas of improvement. You know, we only were able we only looked at one group of contaminants, PBDEs. You know, we selected that based on the state of the evidence at the time. Mm-hmm. Which was that, PBDEs were found elevated in firefighters compared to nonfirefighters. There was evidence of it being detected in breast milk, and some evidence of it s you know, showing changes over time in breast milk as well. And we also only used one measure of toxicity. So there are, you know, there are other outcomes that we could have that can be considered by future researchers and should be, you know, as the the state of the state of the research changes and concerns and needs change as well. I mean the the greatest challenge will be, you know, trying to set up this kind of a study again where you can able to recruit a large enough sample of women who can provide enough samples that can be examined like this. But I mean, I wouldn't I wouldn't would never discount the firefighting community to be able to achieve something like this if they put their minds to it. Yeah. You know, I I know for a fact some of the researchers in the lab that I worked with, you know, at least up until a year or two ago, they were still getting inquiries like, Hey, are you still doing that breast milk study? Can I participate? Can I send you samples? So there's still like there's still strong interest in this and people and you know who are still engaged and want to participate and get answers. So I I mean I I would love to see more being done on this in the future. So let's say that happens. Right. And there's there is a new study based on you know the feedback that you've just described, that there is some demand for it and certainly a need for it. What would you do to expand what the research is, or you know, what other things would you be looking to learn? Well, one thing is that if we were able to recruit a greater number of women. And even a greater number of controls, because though there's the number of controls in your analysis is also a c i a consideration, is that we would be able to adjust for other factors or variables that could have affected either these women's these their exposures themselves or possibly their underlying risk of some of these outcomes. Because we in this analysis, because we were s we had such a s a relatively small number of women, we weren't able to adjust for any of these potential variables or confounders. So I think that would strengthen some of our certainty in the findings that we're able to receive. You know, if we had more women, we could detect smaller change smaller changes if they existed. So we we could speak with more certainty that, you know, yeah, this is we didn't detect any we anything at least up until this point. Yeah. And I think with you know, this study is s several years old at this point. But with the pace of scientific advancement, you know, we're learning more and more about the effects of these chemicals every day, as well as how they're transported through the body, especially if if you're considering excretion through breast milk, and more research is being conducted. So we would have a better foundation of, you know, what's going on. We could, you know, we could possibly consider groups of toxins as well, which I think would be of interest, especially if if we could, you know, get more feedback from the firefighting groups to to find out, you know, what are their like main like exposures of concern. That we could put that we that could also potentially be transported through the body in a in this in a way that would be, you know, scientifically plausible. Right. Mm-hmm. And so what areas of reproductive health for firefighters do you feel right now need more attention or more research? So I think, you know, in I might be a little biased from my own dissertation work. That's okay. We're all biased. I think. So that's fine. Well the caveat that, you know. This was the focus of my dissertation research. I'd love to see more work being done examining these like pregnancy outcomes in women firefighters. I and I mean the big ones are of course are gonna be like adverse pregnancy outcomes. And I think the key to that is being able to better understand or quantify occupational exposures of among women female fighter fighters and being able to link that to a either well-documented or well reported reproductive history for them. because a lot of the times, and and with my dissertation research, I worked with self reported survey data, which was really great. But there are limitations to survey data as well as self-reported information. especially if it was reported, you know, twenty years since the event, right? 'Cause you know, the we you might have had a participant who was in their fifties and they were reporting their how many their pregnancies when they were in their twenties and thirties. So there's a little bit of con there's a little concern how how well people are able to remember these events. Yeah. And so either something that's like where we're able to prospectively collect information. So like, you know, if you're as it's not maybe not as it's happening, but in a more timely manner than just saying, yeah. Twenty years ago. Right. What was you know, when did you have your when did you have your first pregnancy? What what are did you have any of these like events happen? How many fires did you respond to that year? You're they're not gonna remember that information. Right. So if we could if we could have a way to more reliably link an individual's reproductive history with their either their service service or employment records, I think that would be really great. because firefighters who are pregnant or who are who want to become pregnant in the future or planning to become pregnant in the future, they may need to consider like additional ways that they can ensure that they are reducing their exposures to potentially harmful chemicals. And that might be through PPE, it could be through their exposure controls. But we want to make sure that current industry standards are protective enough or if we find a gap, we want to provide information that would support like advancing it further or or provide information on exactly how it could be improved. Mm-hmm. So I think if we're If we're able to better determine what are the risk factors for these adverse events that could really support that effort. I I think I don't know if anyone who wouldn't agree that more research specifically on female firefighters on like almost every way is needed. Yeah, absolutely. And that's why we're doing this. And so that's exact exactly the reason for this conversation. So what questions, if there are any specific questions would you like to have answers to in in the in the research community in the next five to ten years in the area of firefighter health, whether it's specifically what we're talking about here or even more broadly? well, I see a lot of current effort in this area, you know, from my colleagues still at the University of Arizona and like in the in that kind of circle of researchers, but I really love to see a lot a lot of focus on maybe some of the less studied occupational factors, which would be things like diet, the effect of shift schedules on individuals, PTSD, stress, some of the things that are, you know, they are part of the job, the job environment, but they aren't they may not be the first thing you think about when you think of like the risk of being a firefighter, obviously. And I'd love to see more research focused on how they affect even different aspects of firefighter health. I mean, cancer, of course, reproductive outcomes, I would love that. But, you know, other things as well. Because it's it's great that we're like s we're like focusing on these like different aspects of health, but I think we need to consider the health of firefighters in overall, you know, in a more holistically, male like men and women. And I know we're getting there, but it's you always want you always want to go a little bit faster. Yeah. Yeah. Well, and to your point, you know, this this kind of work takes years. And and I would imagine the bigger the project and the bigger the sample, the longer it takes. Mm-hmm. So, you know, it's it's a long road for for any of these, but but they're all important. So and that's why we're here. So thank you for all of that. Is there anything else that you want to share or any other unmet needs within the research that's happening that that you've thought about but haven't talked about here that you'd like to mention? I guess that, you know, again, I even though I'm I have I'm like greatly involved and passionate about firefighter research, you know, I don't have a personal history or connection to firefighting or firefighters. And however, when I got involved, like the individuals that I worked with, they were just so passionate and curious about what was being done or what could be done to improve the health and safety not only of themselves, but of the men and women they worked with, you know, and the families of every of everyone involved, because they are a really tight knit and supportive community that, you know, it's I kinda I've I kinda just fell into this research. I love I I loved every minute of it. I I still love to be involved in these kinds of projects. And one thing that I noticed as a researcher was that and I I think it's something that all anyone who wants to get involved in firefighter research needs to consider is the fact that all of these ideas, they need to be driven by the people you're working with, the firefighting community. And the best way to do that is to get them involved, talk to them. Get I d figure ask them specifically what do you think about what we're doing? You know, how do you think this would help? What could we do better? What kind of ideas do you have, or what kind of questions do you have that you're curious about but you don't see any answers for that you want to see being done? So I would encourage people listening to this is to, you know, share your ideas, talk about these things with people who are interested in like helping and supporting like the firefighters and the firefighting community, because a lot of the ideas, the projects I've worked on over the years, they have been, you know, started by the suggestion, the questions that are being raised by firefighters. Not just like the captains and the chiefs or the people involved in health and safety, but like the actual members. Yeah. Cause that's who knows what's what they need. so thank you though for putting that into words and and I second that that the importance of of reaching out and and who can they reach out to i mean sure they can tell us at firefighter nation but but who else can they if if someone is listening right and they're like we really need more work i need to understand this condition that runs in my family and i come from generations of firefighters and i wonder if those two things are connected I'm just going rogue here, but if if when that kind of an idea comes up, where do they go with it? There are a number of groups at universities, at like NIOSH or CDC that are working with and and involved in firefighter health and safety projects. However, I will give a special shout out to the researchers at the University of Arizona and specifically like Dr. Jeff Burgess, Dr. Melissa Furlong. Who we've had on the show. Yes. and also Dr. Sarah Janke who and Dr. Brittany Hollerbach who have done so much for women firefighters and women firefighter health. And all friends of Firefighter Nation. Yes. And Jeff specifically, he has founded the or he has helps found the Center for Firefighter Health Collaborative Research at the University of Arizona, which you can look up. They have a page. I would love to give them a shout out because they've really expanded from like First focusing on cancer to, other aspects of firefighter health and well being that I think is fantastic. All right. Well, thank you so much. This was really interesting and helpful. And I appreciate the resources that you provided us with that we can share with everyone. and that'll be up on Firefighter Nation when this podcast is available. Okay. So thank you so much for joining us. Great. No, thank you. This was I I was a little nervous at first, you know. But it was a really enjoyable conversation. Great, great. Well thank you so much. And I'm sure we'll stay in touch. Okay. All right. Have a great weekend.