HEPATITIS C and the fire
service: assessing the risk
|The news that Philadelphia (PA)
Fire Depart-ment (PFD) firefighters screened for hepatitis C (HCV) in
1999 had an infection rate almost three times the average for the U.S.
population vividly reminded the fire service that complacency in the
health and safety arena can be as deadly as complacency on the
fireground. The revelation moved fire departments to look more closely
at their infection-control policies and means for protecting their
members against infectious diseases and supporting those who already
have become infected.
|Paramedic Marcellus Hatcher, one
of the first PFD members to be identified as having the HCV infection,
died in 1998 while awaiting a liver transplant. The disease forced him
to retire in 1997, and he ultimately ran out of sick leave. As the
result of a court case fought and won by the Philadelphia International
Association of Fire Fighters (IAFF) Local 22, the state of Pennsylvania
awarded Hatcher's widow his pension. At the time this article was being
written (the middle of October), the Hatcher Case was the only HCV case
that had been settled in Pennsylvania.
|"It is very difficult," says
Stephen Hess, Local 22 public relations director. "You not only have to
fight for your life, but you also have to fight with the city for your
benefits, your good name, and your reputation at the same time. The city
does everything it can in court to try to blame the victim for
contracting the disease, even if the firefighter had no questionable
|Hatcher's experience led Local
22 to look more closely at the hepatitis C issue. Subsequent
prescreenings for a series of union-coordinated Red Cross blood donor
drives showed that a significant number of Philadelphia fire and EMS
workers were infected with HCV.
|In November 1999, 2,146 current
and retired Philadelphia firefighters were screened for hepatitis C
using donated home test kits. Of this group, 97 (roughly five percent)
were found to have the virus. As of July 30, 2000, 152 firefighters
reportedly had the disease. According to union officials, however, more
members have disclosed that they have the disease but do not want to
make it public.
|Treatment for this disease is
costly, and the local has been finding it difficult to pay for the
firefighters' treatments. The city has rejected claims that the
firefighters' illness is related to their work. Philadelphia Mayor John
F. Street, in January, had pledged to make $3 million available to help
firefighters pay for costly medications. That money reportedly has been
difficult to access, however.
|"The union's goal is to have
hepatitis C declared presumptive in the case of emergency personnel, an
in line-of-duty illness, thereby making afflicted firefighters eligible
for workmen's compensation benefits," George T. Casey, a 32-year veteran
of the Philadelphia Fire Department and president of Local 22, explained
in an Open Letter to all Philadelphia firefighters and paramedics.
|The local is also asking the
city to extend retired firefighters' health benefits until the age of 65
instead of having the benefits terminate four years after retirement. An
individual who tests positive for hepatitis C may not even know he has
it and may not experience any symptoms for 10, 20, or even 40 years,
adds Local 22 Vice President Tom O' Drain. That's why, the union says,
firefighters must have lifetime health care benefits. The IAFF is taking
a closer look at retirees, according to George T. Burke, assistant to
the president and director of public relations for the IAFF. "In many
instances, we have lost track of our people; now, we will be monitoring
them in terms of illnesses that may be related to the job that strike
them later in life."
|To draw national attention to
the seriousness of the first responder-hepatitis C problem, Local 22
hosted a rally/march in Philadelphia in August during the Republican
National Convention. The event drew more than 1,400 (some reports put
the attendance as high as 2,000) fire, ambulance, and rescue personnel
predominantly from the East Coast. "There is an ignorance that surrounds
this disease," Hess says. "Firefighters and paramedics deserve the
compassion of all levels of government."
|Among the speakers at the rally
was Pennsylvania State Treasurer Barbara Hafer, a former public heath
nurse. She called for comprehensive testing and better medical care for
fire and rescue workers, whose jobs expose them to the illness. "The
debate over infection rates should not be allowed to obscure the real
issue," she told the crowd. "Whatever the precise statistics may be, the
fact is, thousands of fire and rescue workers suffer from hepatitis C
because they are fire and rescue workers. Because they did what they had
to do to save lives. Because they are heroes-no other reason."
REFUTES PHILADELPHIA FINDINGS
|Responding to health agencies
that had asked the Centers for Disease Control and Prevention (CDC) to
investigate the Philadelphia HCV findings, the CDC ultimately released,
in July 2000, "Hepatitis C Virus Infection Among Firefighters, Emergency
Medical Technicians, and Paramedics-Selected Locations, United States,
1991-2000." The report, part of the Morbidity Mortality Weekly Report,
July 28, [49(29); 660-5], summarized studies the CDC had conducted among
small samplings of firefighters from the Philadelphia, Atlanta (GA),
Miami-Dade (FL), and Pittsburgh (PA) Fire Departments, and the state of
|The CDC had concluded that
although some of these workers may need HCV testing under certain
circumstances, first responders are not at greater risk for HCV
infection than the general population. Routine HCV testing, therefore,
is not warranted, according to the CDC. First responders should continue
to follow standard precautions to reduce workplace exposure to
|Regarding the original
Philadelphia firefighter test results, which the CDC termed incorrect,
the CDC said that it had reanalyzed the serologic and questionnaire data
from the 1999 Philadelphia study and determined that 64 (3.0 percent) of
the 2,136 participants tested had positive readings. (The CDC
firefighter figure was 10 fewer than the original Philadelphia study
figure.) The highest prevalence (4.9 percent) was among men between the
ages of 40 and 49.
|According to the CDC, the 4.5
percent prevalence previously reported by Home AccessT (the agency that
analyzed the blood samples of the Philadelphia firefighters) "was
obtained by classifying as positive 20.6 percent of the serum samples
not tested completely, in accordance with Food and Drug Administration
|Also, the CDC report pointed out
that although the overall prevalence of HCV infection among persons of
both sexes over the age of five was 1.8 percent, the rate was 4.9
percent among men between the ages of 30 and 49-the group that
represents most of the first responders in the CDC studies. Men between
the ages of 40 and 59 currently would have the highest expected
prevalence of infection.
|Healthcare workers' risk for
acquiring HCV infection is low, the CDC says, "because HCV is not
transmitted efficiently through occupational exposure." According to the
CDC, HCV infection among first responders was associated primarily with
|The CDC report noted the
following findings pertaining to the other four regions covered:
Of the 437 firefighters tested in May 2000 (from samples from a
hepatitis B virus infection study among these subjects in 1991), nine
(2.1 percent) were anti-HCV-positive; the highest prevalence (4.0
percent) was among men ages 35 to 39. HCV infection was not associated
with duration of employment as a firefighter, occupational exposures
to blood, history of blood transfusion, or illicit drug use; however,
it was associated with a history of a sexually transmitted disease.
Among the 382 volunteer and paid firefighters and EMTs from whom serum
samples were available, five (1.3 percent) tested anti-HCV-positive;
prevalence was highest (2.6 percent) among men between the ages of 40
and 49. In 1992, the Connecticut Department of Public Health and
Addiction Services had collected on a voluntary basis serum samples
and demographic data from first responders in various regions of
Connecticut for a study of immune response to the hepatitis B vaccine.
These are the samples (anonymously) from which the CDC conducted its
hepatitis C study in June 2000.
Of the 1,314 participants tested between March and April 2000, 35 (2.7
percent) were anti-HCV-positive on the basis of EIA testing alone; 20
(1.5 percent) were confirmed positive for HCV through RNA testing.
Prevalence of anti-HCV was highest (3.7 percent) among men over the
age of 50. Increased risk for HCV infection was not associated with
occupational exposures to blood, type of job (firefighter, EMT, or
paramedic), or duration of employment as a first responder. Hep-C
ALERT, a Florida-based patient advocacy organization, collaborating
with University of Pittsburgh researchers, confidentially obtained the
serum samples and information on occupational risk factors from
Miami-Dade County municipal fire department personnel.
The serum samples
were tested at a commercial laboratory.
Tests conducted during January and March 2000 revealed that five (3.2
percent) of the 154 respondents tested anti-HCV-positive; highest
prevalence (5.2 percent) was among men between the ages of 40 and 49.
Samples were tested for anti-HCV without supplemental or confirmatory
testing. Anti-HCV positivity was not associated with occupational
exposures to blood. University of Pittsburgh researchers had collected
the serum samples and information on occupational exposures from
paramedics working in Pittsburgh.
The CDC recommended the following: (1) Populations with a low prevalence
of Hepatitis B (HBV) infection, including first responders, should not
undergo routine HCV testing unless there is a history of an increased
risk for infection, such as a blood transfusion before July 1992 or
injecting for drug use. (2) For the purpose of postexposure management,
first responders should be tested after a percutaneous or permucosal
exposure to HCV-positive blood. Testing for these types of exposures
could be considered when the HCV status of the source is unknown. (3)
Standard precautions must be used to reduce workplace exposure to
bloodborne pathogens. First responders should be educated about
transmission of bloodborne pathogens, trained in proper safety measures,
and provided with appropriate protective equipment. First responders
also should be vaccinated against HBV and informed of protocols if
percutaneous or permucosal exposures to blood occur.2
The CDC acknowledges that, "because of several limitations, the five
studies summarized in the July report could not exclude the possibility
that some first responders had acquired HCV infection from job-related
exposures." Examples of the limitations given were the following: (1)
The sample size was small; the information on occupational (percutaneous,
mucosal, or skin) exposures to blood was limited; and nonoccupational
risk factors may have affected the evaluation of potential sources for
infection. (2) The findings do not necessarily represent all first
responders in the selected locations or the United States. (3) If first
responders are less likely to have nonoccupational risk factors for HCV
infection than the general population, then the expected prevalence in
these workers might be lower.
The CDC has not studied firefighter or paramedic populations
REACTIONS TO THE CDC REPORT
Many in the fire and emergency medical services do not agree with the
CDC's position and say the agency's statistics should be looked at more
Philadelphia Fire Fighters Local 22 is demanding that the CDC declare
its report on hepatitis C "null and void." The union claims that the CDC
study is flawed, the initial testing results are unreliable, and the
CDC's lack of controls makes the study inaccurate and unreliable.
The IAFF, in a letter dated September 15, 2000, to Donna Shalala,
secretary of the U.S. Department of Health and Human Services, voiced
strong objection to the report's conclusions and recommendations. "We
believe that the CDC's conclusion that emergency response personnel are
not at increased risk for Hepatitis C infection is scientifically
flawed," the letter states. "Moreover, their recommendation that
emergency responder personnel not receive 'baseline' testing for
Hepatitis C is misleading and will make it more difficult to determine
when an infection is occupationally related."
The letter also took exception to the CDC's statement: "This report
summarizes the findings of five studies of HCV infection among first
responders." This statement, the IAFF said, "is untrue and grossly
misleading. Only two of the five 'studies' contain published data, and
both of these efforts were developed and designed to assess issues
related to Hepatitis B. The three remaining 'studies' represent
unpublished data collected during what were primarily Hepatitis C
education and screening programs. Data collected in an uncontrolled and
scientifically flawed manner cannot simply be dubbed a 'study' by the
CDC in order to confer validity ellipse."
The CDC, the IAFF suggested to Shalala, "must undertake a more
comprehensive review of this issue. The review should include scientists
from NIOSH [National Institute for Occupational Safety and Health], who
have a better understanding of occupational safety and health issues,
and incorporate input from fire service personnel with expertise in
occupational health and safety."
"For the CDC to propose that firefighters/paramedics and EMTs in America
are at no greater risk than the civilian population other than those
that may practice hard-core drug addition is absolutely absurd and out
of touch with reality," says Jerry Smith, administrator of the Internet
discussion forum, The Emergency Grapevine. The former Los Angeles City
fire captain adds: "It's beyond reasonable comprehension that a
government agency could be so far removed from the real world."
"The CDC's report was not a 'scientific investigation'; rather, it was a
'review of the literature,'" observes Charles E. Truthan, DO, FACOFP,
medical director of the Cascade Charter Township (MI) Fire Department
and founder of Fire DocTM, P.C. and Fire Doc Services, Inc., which
provide occupational health services for firefighters. In an e-mail
message to Hess, Truthan confirmed that factors identified in the
Philadelphia study are "significant," including the higher infection
rates in certain stations and among retirees and the lack of PPE prior
to 1987. Truthan says the CDC report "opens more questions than it
answers." He questions the interpretation of the data analysis. Some
unanswered questions he lists are the following: Is there a geographic
difference in incidence and prevalence? Why is there an age difference?
Did all first responder organizations institute "universal precautions"
at the same time? If not, is there a difference between those
departments' prevalence of HCV? How "large" and how "repeated" does the
" ellipse large or repeated direct ellipse exposure to blood" have to
be? Most importantly, what about those (31) Philadelphia firefighters
that the CDC excluded from use as a "positive" screen? Have they been
given the required additional evaluation testing? If not, why not?
He says some bad assumptions have been made regarding risk factors as
the etiology of a disease. Using unpublished data [Third National Health
and Nutrition Examination Survey 1988-1994 (NHANES III)] as a basis of
reference is questionable from a scientific standpoint. This unpublished
CDC study was used to establish a national HCV prevalence rate of 1.8
Until these questions are answered, Truthan asserts, first
responders-along with other healthcare workers-should remain in the
"high risk factor" for HCV group.
Testing only some members of a department may create a biased population
and yield erroneous results as far as the infection rate for the overall
department, says Andi Thomas of Hep-C ALERT. "It is difficult to compare
the Philadelphia and Miami-Dade rates," she explains, "when only half of
Philadelphia's firefighters were included in the testing. The Miami-Dade
rate applies to 94 percent of the firefighters." Moreover, the
discrepancy in rates between firefighters in Philadelphia and
Miami-Dade, Thomas says, "would depend [also] on what happened 10 years
ago, when work processes modified." Fire departments that were more
proactive in implementing new safety precautions would have lower
infection rates, she adds.
Part 2 presents some suggestions for mounting an offensive against
hepatitis C and other infectious diseases and actions some fire
departments have taken to protect their members.
The International Association of Fire Chiefs (ICHIEFS) strongly
recommends that an overall wellness program include routine liver tests
and baseline hepatitis C testing. This is underscored in the ICHIEFS and
IAFF Joint Wellness Fitness Program, available on request from ICHIEFS,
4025 Fair Ridge Dr., Fairfax, VA 22033-2868, or it may be downloaded
from the IAFF Web site: http://www.iaff.com (select "health & safety"
and then "fitness & wellness").
complete CDC report, "Hepatitis C Virus Infection Among Firefighters,
Emergency Medical Technicians, and Paramedics-Selected Locations, United
States, 1991-2000," July 28, 2000/49(29); 660-5, is z.
American Liver Foundation
1425 Pompton Avenue
Cedar Grove, NJ 07009-1000
Centers for Disease Control and Prevention (CDC)
Hepatitis Branch, (888) 443-7232, (4HEPCDC)
Charles E. Truthan, D.O., FACOFP
F.D. DocT, P.C. and Fire Doc Services, Inc.
http://www.FD-DC.com e-mail: info@FD-Doc.com
Frontline Healthcare Workers Safety Foundation
Hepatitis Foundation International
30 Sunrise Terrace
Cedar Grove, NJ 07009-1423
Hollywood, FL (954) 920-5277, ex. 101
Katherine West, BSN, MSEd, CIC infection control consultant in Manassas,
(703) 365-8388, e-mail: email@example.com.
National Digestive Diseases Information Clearinghouse
National Hepatitis C Coalition, Inc.
Smyrna, TN 37167 HepLine (615) 355-8604
National Institute of Health
Occupational Safety and Health Administration
Surgeon General David Satcher's Hepatitis C Campaign
Hepatitis C: Some General Information
Hepatitis C (HCV) is a viral infection that inflames, injures, and
ultimately scars the liver. It is a chronic disease caused by a
bloodborne pathogen. It affects four to five times as many Americans as
Symptoms are usually milder than those of acute hepatitis B infection;
many infected people do not know they have the disease until many years
after the exposure. Often, the initial symptoms are mild and flu-like.
No vaccine is available for hepatitis C. Drug therapies are available.
Early detection is essential to preventing serious liver disease.
Hepatitis C is transmitted through (not in order of risk)
(8 to 10 percent before 1990; less than 0.5 percent after 1990);
medical treatment, such as dialysis;
intranasal use of
instruments (scissors, razors); and
tattooing and body
The International Association of Fire Fighters has a film on hepatitis C
that is being made available to its affiliates. The National Volunteer
Fire Council (NVFC), in partnership with Schering/Oncology Biotech, was
producing, at press time, an educational video on hepatitis C in the
public safety community. For additional information contact Heather
Schafer, NVFC, at (1-888)-ASK-NVFC (275-6832).
Understanding the CDC Study Data
By Katherine West, BSN, MSEd, CIC-Looking at the study data
(confirmatory tests results as well as initial screening tests) for the
Anne Arundel County (MD) Fire Department (2.2 percent) and the Atlanta
(GA) Fire Department (2.1 percent), which were first published in 1995,
and the CDC infection rate of 3.0 percent rate for the Philadelphia Fire
Department, it looks as though the risk for emergency responders is
greater than that for the national population (1.8 percent). However,
that is not the case when the numbers are adjusted for age group.
Nationally, in the 20- to 59-year age group, the rate of positive test
results is 3.7 percent, which is higher than the three rates in these
fire department studies. The numbers are within the expected rate (one
to four percent) for positive responses in health care workers. The
testing information of the departments and the state of Connecticut
reported in the CDC July 28 report further support these data (see Table
Study after study shows that the risk for infection in health care is
related to sharps injuries; 80 percent of health-care worker exposures
have been shown to be related to sharps injuries. Transmission of HCV is
related to large or repeated percutaneous exposures. That is the reason
the Occupational Safety and Health Administration (OSHA) requires the
use of needle-safe devices in providing health care.
The CDC recommends that testing be done following an exposure to blood.
If an exposure occurs, the exposed emergency worker should be baseline
tested for HCV; the results should be recorded. A positive result
indicates that the infection is not related to this particular reported
exposure. If the test result is negative, and the source patient tests
positive, the department member should be tested for antibody to HCV and
have an ALT (liver study) performed. Retesting by hepatitis C-RNA four
to six weeks later will determine if the provider had acquired the
disease as a result of the exposure.
Should a Screening Test Program Include?
The HCV virus is transmitted blood-to-blood and is also a sexually
transmitted disease. Testing for baseline on hire does not eliminate the
possibility that an individual may acquire the disease as the result of
off-duty activities. HCV infection is a protected disability under the
Americans with Disabilities Act: You must obtain consent for testing,
and confidentiality of test results must be maintained.
The screening test program should have the following characteristics:
It must be
comprehensive and address all aspects for a formal program, including
these considerations: What is the next step if someone tests positive?
Who will be responsible for additional costs? How will we
handle/store/protect sensitive/personal information?
List the pros and
cons associated with such a program: consideration of the CDC
recommendations, legal considerations, and cost factors.
Establish a working
committee to formulate a program. You are at high risk for liability
if you do not have a formal plan in place.
following components in your plan:
appropriate information on HCV,
a referral process
for additional medical care and treatment,
access to mental
health professionals and support groups,
two-step testing by
an accredited laboratory,
confidentiality of test results,
and allocation, and
developed with legal input.
Reference: "What the fire chief needs to know," On Scene, International
Association of Fire Chiefs, September 2000. Printed with permission.
MARY JANE DITTMAR is associate editor of Fire Engineering. Prior
to joining the Fire Engineering staff 10 years ago, she had served as
editor of a trade journal in the health/nutrition industry and headed
MJD Promotional Services. She has a bachelor's degree in
English/journalism and a master's in communications arts.
Author(s) : Mary Jane Dittmar