Viral workload

When Philadelphia headlines shouted “Hep C Epidemic in Firefighters” a few years ago, the entire community turned to the Centers for Disease Control and Prevention for guidance and direction. But did we hear what they had to say?

The impact of hepatitis C among first responders originally was heralded to be at epidemic proportions. These claims created a major conflict between fire service administration, labor unions, public health organizations, and worker's compensation and risk management concerns. The demand for scientific evidence to support or refute the claims of alarming rates of chronic hepatitis C infection caused the CDC to review available sero-prevalence data among U.S. first responders.

Firefighters have a significant risk of occupational exposure to bloodborne pathogens as a result of the conditions in which they work and the tasks they perform. Over the last 15 years, due in great part to fear of HIV, there has been considerable focus on universal precautions.

The chance that a needlestick exposure may lead to the development of hepatitis C is relatively low, between 2 and 10%. In comparison, the same risk for hepatitis B is 30%, hence vaccination recommendations. Where vaccination is unavailable, as in the case of hepatitis C and HIV, prevention strategies are critical.

The CDC concluded that although some first responders needed HCV testing under certain circumstances, as a group they weren't at greater risk for hepatitis C infection than the general public. Despite significant limitations in these data and protest by the International Association of Fire Fighters, the CDC's final recommendation was clearly against routine HCV testing.

Whatever impact the CDC's recommendations have had and continue to have, more and more first responders are being tested and diagnosed each year with chronic HCV. Steps must be taken to implement interventions aimed at preserving the health and safety of all firefighters.

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Routine versus baseline

The phrases “routine testing” and “baseline testing” aren't interchangeable. Routine testing is performed on a periodic recurring basis, such as testing to monitor cholesterol levels. Alternately, baseline testing is used once to establish the evidence or absence of a health condition or specific disease, at a given time.

In the case of hepatitis C in first responders, baseline testing is a one-time event intended to achieve two objectives:

1. Prompt detection and medical evaluation of existing HCV infections, and

2. Establishment of each employee's hepatitis C status for effective monitoring of exposure control programs.

A cost-effective approach is to conduct a one-time baseline testing program for current personnel, and to add HCV testing to the employment physical for new hires as well as for new bloodborne exposures. This model screens all affected personnel and detects previously undiagnosed infections so that those employees can be medically evaluated.

The sero-status of new personnel is recorded in the event of future disability claims and to ensure that personnel newly exposed to potentially infectious blood or bodily fluids receive proper post-exposure management for HCV. With this approach, an annual, or routine, HCV testing program for previously tested personnel would be neither cost effective nor necessary.

In addition, as more states consider and adopt presumptive exposure legislation, the burden of establishing the source hepatitis C infection is shifting to the employer. Baseline testing then becomes a vital tool that protects both the fire department and employee.

The healthcare provider must give baseline blood test results directly to the employee in a timely manner. The test results should be sealed to the employer and should remain sealed unless there is a specific event, such as a claim for worker's compensation or request for disability benefits associated with hepatitis C.

There are no recommendations by the CDC to restrict work activities for healthcare or emergency responders infected with the hepatitis C virus, so a positive baseline test result should have no bearing on current or future hiring, employment or promotion decisions. Decisions made based on an employee's hepatitis C status would be discriminatory.

The cost of confusion

Regardless of the recommendations for baseline testing by the IAFC and the IAFF, the CDC's report caused many departments to delay the implementation of these programs.

Reaching a decision to offer testing is complicated, because fire service administrators are accountable to a variety of individuals. The locality's governing body, union, comptroller, risk manager, attorney and worker's compensation carrier all have a vested interest and should be directly involved with the fire department health and safety team's evaluation process. Evaluation should review the cost of the hepatitis C test, the benefits gained, the structure of delivery of the testing service, the reporting mechanisms and, most importantly, whether the fire department intends to provide medical care for newly diagnosed firefighters.

It's common for city administrators to solicit advice from health care providers in their community, such as the department's medical director, occupational medicine physician, local hospital infection control nurse or public health department epidemiologist. In almost all consultation cases, these providers recite the CDC's most current recommendations, which conflict with the IAFC and IAFF recommendations.

Mounting a response to hepatitis C is complex. It's incumbent on fire service officers to educate themselves so they can make a strong case to define the benefits and justify the costs associated with baseline hepatitis C testing.

In 2000 and 2001, Hep-C Alert conducted hepatitis C education and baseline testing programs in 11 different states and tested more than 7,000 first responders. For each department served, we helped at least two others gather the information needed to develop their own program.

In our experience with these departments, the most frequent barrier to testing was conflicting recommendations from consulting health care providers. Other barriers were shifting priorities and limited budgets for employee health and safety initiatives.

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Testing approaches

Even with these barriers, many fire departments have implemented hepatitis C testing programs. Departments have used multiple approaches to do this — some effective, most not.

While fire and EMS trainers try very hard to do a good job setting up these programs, many simply don't understand confidentiality or legal and post-test counseling issues and have little time to conduct in-depth research. These well-intended testing programs have the potential to create larger problems for the fire department.

The most-often applied approach is for the fire department to add the hepatitis C antibody blood test to the list of diagnostic and health screening tests available to personnel during a periodic employment physical examination. Although this seems cost and resource efficient, it can be fraught with complications.

Few of the fire service officers had carefully considered the ramifications of offering “just the hepatitis C test” in isolation of meaningful education, pre-test counseling, informed consent and post-test counseling. Furthermore, local hospital or occupational medicine providers usually aren't trained well enough to provide hepatitis C counseling.

What these departments ended up with were personnel who tested positive for the virus but had no safety net for individual and family counseling, medical referral, health education, support, and maintenance of confidentiality.

Managing confidentiality

The missing link in maintaining confidentiality has to do with using standard exposure-reporting methods for newly discovered existing infections.

Reporting a chronic hepatitis C infection is much different than reporting a typical bloodborne exposure, where the exposed employee first reports the incident to a supervisor, who then follows a standard operating procedure and chain of command for injury evaluation and referral for acute medical care. Under normal circumstances, at no time do the contacts in the chain of command learn of an employee's sero status.

However, using this procedure to report an existing chronic hepatitis C infection undermines the confidentiality of the first responder. The chain of command is made intimately aware of the first responder's health status.

The stigma associated with having a hepatitis C infection and concern over job safety become major deterrents in the employee's decision to access whatever hepatitis C testing benefit the department may offer and to report the infection.

Personnel who undergo testing must have reasonable assurances of confidentiality, as well as appropriate education, informed consent and post-test counseling. Many departments have hired Hep-C Alert to conduct their hepatitis C education and testing program because we specialize in this service. A key element of our program is selecting one entity, usually the infection control officer, as the only person in the department for personnel to contact to report a newly discovered chronic infection.

Departments considering an independent implementation of hepatitis C testing should structure their program to include the six components of HCV training and testing:

1. Education.

2. Pre-test counseling.

3. Informed consent.

4. Reliable testing methodology, such as running confirmatory tests.

5. Post-test notification by qualified counselor or health provider.

6. Maintenance of confidentiality and protection from discrimination.

Better tools for better data

Quality fire and emergency rescue service begins with a healthy work force and a safe work environment where personnel are protected from the risk of exposure to infectious diseases. However, occupational exposures still occur despite engineering controls and personal protective devices.

Unfortunately, there are no data that demonstrate the frequency, risks or outcomes of these injuries among firefighters or rescue personnel. Most departments lack the evidence needed to verify the efficacy and justify the costs of their infection control programs.

Historically, the fire service has lagged behind the medical industry at protecting its personnel from bloodborne pathogens. There's a great need for a more uniform approach to monitoring infectious exposures among fire and rescue personnel throughout the country.

For example, one major advance in the hospital-based setting was EPINet, a computer program developed by the International Healthcare Worker Safety Center at the University of Virginia.

EPINet provides standardized computerized methods for recording percutaneous injuries and blood and body fluid contacts to assist hospitals in complying with the OSHA record-keeping requirements. Hospitals use the system to record, compare and share information and identify successful prevention measures, which has resulted in a safer working environment and thorough understanding of occupational exposures in the hospital setting.

There's no equivalent available for the fire and emergency services to monitor these occupational exposure data. The development of best practices and cost containment for exposure control will be an elusive goal as long as exposure data is gathered and reported haphazardly.

Where do we go from here?

There are several positive steps that every department can take.

· Continue to work with the rank and file to promote safety issues and recognize new areas of concern when they develop.

· Creatively locate funds to support employee health initiatives.

· Prioritize bloodborne pathogen safety, reporting and monitoring initiatives whenever possible.

· Increase the number and competency of training officers capable of delivering quality hepatitis C education.

· Identify, test and implement new engineering controls to prevent needlesticks and mucosal exposures.

· Update current exposure control policies to include and specifically address hepatitis C.

· Conduct a retrospective analysis of bloodborne exposure reports to identify personnel who were exposed and evaluated for HIV and hepatitis B, but never tested for hepatitits C.

· Carefully research all hepatitis C testing options to ensure that a system of education, counseling and referral is in place before offering this service to firefighters.

· Be certain that there are clear-cut mechanisms to record exposures to bloodborne pathogens, and that these are available to personnel every day, all day.

· Document in writing, all exposure incidents. If an individual is concerned that he or she may have been infected, offer testing.

To quote an old proverb: “Action is the proper fruit of knowledge.” Fire administration must not only implement, but also enforce their exposure control programs. No fire officer would ever tolerate personnel on the fireground without all of their bunker gear. The same expectation of compliance with policy should be applied here.