Andi Thomas, Executive Director, Hep-C
Alert Inc., and Michael Dailey, M.D.
Apr 1, 2002 12:00 PM
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
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
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.
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:
Prompt detection and medical evaluation of existing HCV
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
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
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
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
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.
The missing link in maintaining confidentiality has to do with
using standard exposure-reporting methods for newly discovered
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
Departments considering an independent implementation of
hepatitis C testing should structure their program to include
the six components of HCV training and testing:
Reliable testing methodology, such as running confirmatory
Post-test notification by qualified counselor or health
Maintenance of confidentiality and protection from
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
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
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.