Hep C in the Fire Service:
Should You Be Worried?
WRITTEN BY : Rebecca Richardson / FireFighting.com Staff Writer, DATE POSTED: 2/21/01

http://www.firefighting.com/

Do fire, rescue and EMS personnel face a higher risk of being infected by Hepatitis C than the general population? They're often exposed to victims’ blood and only recently have the precautions been put in place to protect them from exposure to blood-borne diseases. The answer to that question would seem obvious.

But logical assumptions and hard clinical proof are two very different matters. In the last year, several organizations have begun efforts to gather statistical data on the prevalence of Hepatitis C in first responders. The reports are both conflicting and confusing.

The issue is important, because if it can be statistically proven that first responders show a higher risk of being infected than the general population, the jurisdictions they work for may be required to pay the costs of medical treatment when personnel come down with the disease. A death from Hep C could also be considered a line-of-duty death, qualifying your survivors for the same death benefits as a death from any other on-the-job hazard.

HEPATITIS C BASICS
Hepatitis C is the third (hence the C) and most recent form of hepatitis, or inflammation of the liver. Thought to be caused by a persistent virus transmitted through blood, it was first reported in 1975 and recognized as a distinct form of serum hepatitis in 1989, when it was named the Hepatitis C Virus (HCV).

Hep-C ALERT, a nonprofit organization in Florida dedicated to public education and research on Hepatitis C, estimates that 1 in 50 people in the United States (2 percent) are infected. Often called "The Silent Epidemic," the disease can linger without symptoms for decades while causing serious liver damage. Persistent liver disease develops in 60 to 70 percent of people with chronic Hepatitis C, with people suffering the greatest risk of death from the disease at ages 40 to 49.

According to Hep-C ALERT, 8,000 to 10,000 people a year die from Hepatitis C in the United States. The only way to know for sure that you have been infected is by a blood test.

THE LATEST REPORTS
Recently, the results of two studies of Hep C in first responders have been reported. In January, Hep-C ALERT released a preliminary review of the results of Hep C testing conducted on 12 public safety departments in Florida. The participating agencies were Miami-Dade Fire Rescue, Jacksonville Fire Rescue, Broward County Fire Rescue, Dania Beach Fire Rescue, North Lauderdale Fire Rescue, North Lauderdale Police, Titusville Fire Rescue, Titusville Police, Melbourne Fire Rescue, Volusia County Fire Rescue, Volusia County Beach Patrol, and Key Biscayne Fire Rescue.

About 96 percent of the responders with these departments participated in the testing, 3,360 in all.

The study found 2.4 percent of the participants tested positive for the Hepatitis C antibody, with an additional .3 percent self-reporting prior diagnosis of the disease. That 2.4 percent rate is not significantly higher than the rate of the general population and was much lower than the figure reported by a study of Philadelphia firefighters last year.


Philadelphia’s Local 22 of the International Association of Fire Fighters conducted tests of its firefighters and reported a 6.8 percent rate of infection, much higher than the rate in the general population.

Why were the numbers in Florida lower than those found in Philadelphia? Comparing the data is difficult. Hep-C ALERT’s data came from a university-sanctioned research study with only active responders participating. Data was gathered that enabled the researchers to break down the results into age groups, duration of employment, race, gender and work-related risk factors, which provided significant data.

The testing in Philadelphia was done through the union and no information was gathered to enable results to be broken down by age groups. The testing was open to all members of the union, including retirees.

About half of Philadelphia's members have been tested using a home medical screening test (Home Access). Among the people tested there is a 6.8 percent rate of infection, according to Stephen Hess, public relations director of Local 22.

Later, the Centers for Disease Control (CDC) evaluated Philadelphia’s study and came up with a lower estimate of 3 percent overall infection rate for the department.

The IAFF has refuted the CDC’s figure. In a letter written by Harold A. Schaitberger, General President of the IAFF, in September 2000 he states, "The data that the CDC received from Home Access Health Corporation reflects only a fraction of the Philadelphia fire fighters that tested positive for Hepatitis C because of serious selection bias issues. A significant number of fire fighters that had previously tested positive for Hepatitis C elected not to participate in the Home Access screening program because it was unnecessary. Our local affiliate has identified 155 Hepatitis C positive fire fighters, a great deal more than the 64 that the CDC acknowledges."

ANY NUMBER IS TOO HIGH

Are the numbers really what is important? Andi Thomas says no. "As we spend possibly years debating what the numbers mean, infected firefighters are becoming sicker. If left untested and untreated, many first responders will manifest serious liver disease in the next several years. As long as anyone is testing positive, the issue should not be how many, but how to help them."

Rich Duffy, IAFF Director of Health and Safety, concurs. "Departments need to test both incumbent and new employees to get a baseline. Fire departments ignoring this issue are basically sticking their heads in the sand," he says.

Schaitberger also stated in his letter to the CDC: "While routine periodic testing for Hepatitis C may not be warranted, a strong argument can and should be made for baseline testing of all incumbent emergency response personnel as well as subsequent new-hires. Baseline testing will identify personnel with Hepatitis C and afford them the opportunity for timely counseling and treatment. Baseline testing will also assist in identifying personnel who subsequently develop Hepatitis C from a work-related exposure. While we agree that post-exposure testing is appropriate, it is important to recognize that emergency responders have unrecognized exposures due to the nature of their work and that there are often occupational barriers (e.g., complicated reporting procedures, social stigma, retaliation) to reporting exposures and receiving the appropriate medical care. It is also important to recognize that there are tens of thousands of emergency responders that had occupational exposures to blood early in their career that were not detected or documented because of the lack of awareness, lack of knowledge, and lack of a mechanism to report exposures. It is the position of the IAFF, as well as others in the fire and emergency services, including the International Association of Fire Chiefs, that all incumbent and newly hired employees receive a baseline Hepatitis C test and that all members also be provided with appropriate post-exposure testing, education, and treatment."

Case in point: Firefighter Jack Barker of Tampa (Fla.) Fire Rescue. Barker, age 45 and a 22-year veteran firefighter and paramedic with the department, passed away in January of this year from complications of Hepatitis C. He was diagnosed about five years ago, though doctors could not pinpoint when he contracted it. In an article in the St. Petersburg Times, Tampa Fire Rescue spokesman

Capt. Bill Wade said Barker is presumed to have been exposed to Hepatitis C through contact with an infected person's blood sometime during the late 1980s or early 1990s.

Wade is quoted as saying that at that time experts did not realize the disease posed a threat to emergency medical technicians.

Philadelphia also has lost one firefighter/paramedic to Hepatitis C. On September 18, 1998, Paramedic Marty Hatcher died of liver failure attributed to Hepatitis C. Hatcher's widow, Geneva Hatcher, was forced to fight in workman's compensation court for in line-of-duty status for her husband's illness.

According to the IAFF, in February of 2000 a Chicago firefighter passed away of Hepatitis C, which was contracted on the job.

THE CDC REPORTS
Currently, one of the greatest obstacles to those trying to get Hep C recognized as a job related hazard are reports from the CDC. If firefighters are exposed to greater risk than other occupations of contracting Hep C, the CDC doesn’t recognize it.

Last July, the CDC issued a report stating that first responders are not at any greater risk of contracting this disease than members of the general population. (The CDC MMWR Weekly July 28, 2000 / 49(29);660-5 Hepatitis C Virus Infection Among Firefighters, Emergency Medical Technicians, and Paramedics --- Selected Locations, United States, 1991—2000).

The report said that although some first responders may need HCV testing “under certain circumstances,” routine HCV testing was “not warranted.” But it also concluded, “First responders should continue to follow standard precautions to reduce workplace exposure to blood-borne pathogens.”

The CDC said HCV prevalence reported in studies in subpopulations should be compared with appropriate reference groups from the general population. In a study conducted between 1988 and 1994, the study found men aged 30 to 49 years old had an infection rate of 4.9 percent. That group represents most of the first responders in the CDC’s five studies.

It’s a chicken vs. egg question. The CDC won’t recommend baseline testing of first responders, but until baseline testing becomes standard in most fire departments, it will be impossible to determine the extent of Hep C in the ranks of firefighters.

EDUCATION INITIATIVES

One thing that everyone does agree on: Education on the subject of Hep C is imperative, both for emergency workers and the leadership of their departments.

Many firefighters and EMS personnel still harbor the misconception that the shots they received for Hepatitis B protect them from Hepatitis C as well. There is no vaccine for Hepatitis C.

The IAFF has been working to educate its members. It has produced pamphlets in the past and soon will be mailing new educational materials, including pamphlets, posters, and videos, to all its locals. It will also be adding a section on Hepatitis C to its Web site.

Volunteer rescue workers have the same risks of contracting the disease as career personnel, and they need to be just as well educated. Heather Schafer, executive director of the National Volunteer Fire Council (NVFC) says there are no statistics available on the illness in the ranks of volunteers. The NVFC, along with Schering Oncology Biotech, is creating educational materials on the topic, including videos, that will be available to all volunteer and combination departments at no cost. These materials are expected to be available in the next few months.

ARE YOU COVERED?
Today, the critical issue is who pays for treatment when firefighters become ill with Hepatitis C. Firefighters who have been on the job for many years didn't have a baseline test for Hepatitis C when they came on the job. Many people never even knew it existed. If they test positive now, how do you decide whether the disease was contracted on the job?

Right now in many departments there is no real criteria to make that decision.

In many departments it is being decided on a case-by-case basis with the burden of proof falling to the infected employee.

The city of Philadelphia initially denied every Hepatitis C claim filed by members of the Philadelphia IAFF Local 22, according to Hess.

The battle between the city and IAFF LocaI 22 is still ongoing. "It is our ultimate goal as a Union of Professional Firefighters to have in-line-of-duty status given to this deadly disease," says a union statement.

The state of California recently passed a law that says public safety workers who become infected with Hep C are presumed to have contracted it on the job, which makes them eligible for workers’ compensation benefits. Florida has a similar law in place.

If it’s difficult for career responders to get medical treatment for Hep C covered by their employers, it’s an even more complicated issue for volunteers. In some states, worker’s comp does not cover volunteers who become injured in the course of responding to a call—even for injuries obviously suffered in the line of duty, much less Hep C.

THE OUNCE OF PREVENTION
While state and local governments sort out their legal responsibilities in the Hep C issue, all departments should have programs in place to protect responders from Hep C and other blood-borne diseases.

The following regulations and standards are in place to protect and educate rescue workers:

29 CFR § 1910.1030: Occupational Exposure to Blood-borne Pathogen
This standard requires that rescue agencies provide a comprehensive education and control program for fire and rescue personnel who may be exposed to blood-borne pathogens or infections materials. The program must cover the following topics: training for rescuers about the dangers of blood-borne pathogens; how to dispose of contaminated materials; disposal processes for sharps, contaminated instruments, and infectious materials; documentation of rescuer exposures to infectious materials; and post-exposure medical evaluations. The rescue agency is required to provide all protective equipment that is necessary to protect the employees from blood-borne pathogens. Hepatitis B vaccinations must be offered at no cost to rescuers.

NFPA 1581: Standard on Medical Requirements for Firefighters
This standard provides minimum guidelines for infection control in the fire station, at an incident scene, and other areas of operation. It covers training and education, appointing an infection control liaison, immunization and testing procedures and exposure procedures, disinfecting, cleaning, and storage in fire department facilities, emergency medical operations protection, including infection control garments and equipment and handling of sharp objects, and cleaning, disinfecting, and disposal procedures.

The U.S. Fire Administration also offers a free guide to establishing an infection control program, “The USFA: Guide to Developing and Managing an Emergency Service Infection Control Program ( Publication ID:40 FA, Number:FA-112). The guide can be ordered online in the Publications area of the USFA Web site at http://www.usfa.fema.gov/usfapubs.

MEANWHILE, PROTECT YOURSELF
Of course, all first responders can help reduce their risk of their exposure to Hep C and other blood-borne diseases by practicing proper body substance isolation and infection control techniques in the field.

If your department offers Hep C testing, consider getting the test, if not for peace of mind to document your status.

If your department doesn’t offer the testing for Hep C--or if you prefer to go to an outside source--you can get tested through Hep-C ALERT for $25 anywhere in the U.S. at national reference laboratory patient service sites.

Document and report in writing any incidents where you may have been exposed, and if you’re concerned that you may have been infected, get tested. If you later develop Hep C, this documentation will help make the case that you contracted it in the line of duty.

Anyone concerned about their exposure can also call Hep-C ALERT's toll-free hotline, 1-877-HELP-4-HEP (1-877-435-7443), for a confidential health-risk assessment and referral for a blood test.

Hep-C’s counselors are available Monday through Friday, 9 a.m. to 5:30 p.m. Eastern Standard Time, and Saturday 10 a.m. to 1 p.m. EST.
For more information on Hepatitis C and blood-borne pathogens:

Hep-C ALERT: http://www.hep-c-alert.org/

National Hepatitis C Coalition: http://nationalhepatitis-c.org/

CDC Viral Hepatitis: http://www.cdc.gov/ncidod/diseases/hepatitis/c/

Preventing Needlestick Injuries in Health Care Settings: http://www.cdc.gov/niosh/pdfs/2000-108.pdf

Philadelphia Firefighters Local 22: http://www.local22iaff.com/


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