HEPATITIS C and the fire service part 2: MOUNTING AN OFFENSIVE

Part 1: “Assessing the Risk” appeared in the December 2000 issue.

The Centers for Disease Control and Prevention (CDC) report, issued last July, has been making it more difficult for some firefighters and EMS workers who have contracted (or will contract) hepatitis C (HCV) to get health and insurance benefits. In Philadelphia, for example, attorneys, taking their lead from the CDC report, say there has been no conclusive evidence that the afflicted firefighters have contracted the disease at work.

The CDC study also may lead some departments to delay implementing policies and testing programs that will protect workers from contracting infectious diseases and detecting an infection early enough to delay or prevent serious health consequences.

Other departments, fire service and health-affiliated organizations, and legislators, on the other hand, have been proactive in warding off and dealing with the situation. Efforts have been exerted in various areas, including the following.

LEGISLATION

• The Needlestick Safety and Prevention Act (H.R. 5178, S. 3067). This legislation, signed into law by President Clinton in early November, authorizes revisions in the Occupational Safety and Health Administration’s (OSHA) bloodborne pathogens standard. The new directive stipulates that sharp objects, such as needles and scalpels, used by healthcare providers should be equipped with “advanced protection features.” According to Craig Moulton, an industrial hygienist with OSHA’s Office of Health Compliance Assistance, the products should provide a barrier between the hands and the needle after use. OSHA also requires that healthcare facilities update their plans for dealing with disease-causing substances that could be transmitted through blood and provide staff members with specialized training.

Some states, including the following, have passed their own needlestick prevention legislation: California (1998), Tennessee (1999), Maryland (1999), and Texas (1999). Iowa, New Hampshire, Ohio, and Wisconsin have been considering or are drafting such legislation.¹

• The Emergency Response Employees Disease Protection Act of 2000. Introduced in the House of Representatives in February, this measure would provide $10 million for a study and demonstration project regarding cases of HCV among emergency responders (volunteer and career firefighters, paramedics, and emergency medical technicians). The secretary of the U.S. Department of Health and Human Services (HHS), in consultation with the Secretary of Labor, would estimate the rate of prevalence of HCV and the likely means through which firefighters, paramedics, and emergency medical technicians employed by or who are volunteers of local government units became infected with the disease. The HHS would report to Congress no later than one year after the passage of the bill. The bill was referred to the House Commerce and Subcommittee on Health and Environment.
• The Fire Investment and Response Enhancement (FIRE) Act. At press time, the House and Senate had passed a version of this bill as part of the Fiscal Year (FY) 2001 Defense Authorization Act (H.R. 4205), which President Clinton signed into law. Appropriations, however, had not been made when Congress adjourned for the Election Day recess. One provision of the act would be a FY 2001 $10 million expenditure for the study of HCV and the risk it presents for first responders.
• New York State Law. Legislation directs the commissioner of health to develop educational materials relative to the “diagnosis, treatment, and prevention of HCV for health care professionals and persons at high risk for contracting this disease.”

• California Hepatitis Presumption Bill. On September 16, 2000, California Governor Gray Davis signed into law SB 32, a hepatitis presumption bill. Authored by State Senator Steve Peace (D-El Cajon) and cosponsored by the California Professional Firefighters (CPF), it provides presumptive workers’ compensation benefits for firefighters and law enforcement personnel who contract hepatitis while performing their job-related duties. The contraction of hepatitis will be presumed to be job related unless the employer provides evidence to controvert this fact. Without such evidence, the Workers’ Compensation Appeals Board would be “bound” to rule that the disease was industrially caused. This presumption is also extended to members who have terminated employment for up to a maximum of 60 months from the last date actually worked. [Source: Ken Buzzell, president, United Firefighters of Los Angeles City Local 112 International Association of Fire Fighters (IAFF), AFL-CIO-CLC.]

INFECTIOUS DISEASE-CONTROL PROGRAM

Miami-Dade’s low rate of HCV infection in relation to other emergency response agencies, suggests Andi Thomas of Hep-C ALERT, a Florida-based nonprofit organization devoted to hepatitis C public education, counseling, and research, may be the result of the department’s progressive and aggressive policy for handling occupational safety and health issues. Miami-Dade has dedicated an entire department to this assignment, she points out.

The International Association of Fire Fighters (IAFF), on the other hand, says that Philadelphia has one of the worst records for protecting its firefighters and medics from job-related illnesses, injuries, and disease. “It’s probably one of the reasons its firefighters and medics seem to have a high rate of HCV,” observes Rich Duffy, the IAFF’s health and safety director. The city, until recently, didn’t even have an infectious disease control officer, notes George T. Casey, president of Philadelphia Fire Fighters Local 22.

Duffy said he’d be surprised if infection rates were high in cities like San Francisco, which has been proactive in its efforts to protect firefighters from infectious diseases. The rates have been lower than the national average in cities like Phoenix and Tucson, Arizona, and Portland, Oregon, he theorizes, because they have aggressive education, testing, and training programs. He contrasted these departments with Philadelphia, which he said “hasn’t even considered an infection-control program and doesn’t provide annual physicals for its firefighters and medics.”

EDUCATION AND TESTING

Departments should implement educational and testing programs for all firefighters, including those newly hired.

Since accurate testing for HCV wasn’t available until 1992, Thomas of Hep-C ALERT notes that anyone tested for exposures to blood before this time should be retested: “There’s a whole population out there with documented exposures since before 1992 who were only tested for HIV and hepatitis B (HBV). They need to go back.”

Firefighters may have been exposed before universal precautions, gloves and face masks, were instituted. The majority of responders who have contracted the disease are 15- to 20-year veterans, points out Les Yost of Philadelphia Fire Fighters Local 22.

The Miami-Dade Fire Rescue Department and Hep-C ALERT initiated a national pilot program for determining the prevalence of HCV among firefighters, paramedics, and emergency medical technicians. Miami-Dade Fire Rescue personnel participated in the screenings and educational workshops conducted at Miami-Dade Emergency Medical Service headquarters.

Miami-Dade Fire Rescue will consider personnel newly diagnosed with HCV as having been exposed in the line of duty; the burden of proof will not be shifted to the infected employee. The initiative was developed cooperatively by Miami-Dade’s IAFF Local 1403 and its Fire Rescue Occupational Safety and Health Bureau, Infection Control, EMS Training, and Risk Management departments.

The Durham (NH) Fire Department advised in an October press release that it is offering voluntary screening for HCV to all of its full-time members as part of their annual physicals. Firefighters are also offered screenings for HBV, HIV, and tuberculosis, according to Durham EMS Coordinator James Lapolla. “While the threat may seem small in rural areas,” says Chief Ronald O’Keefe, “early detection is key to preventing the spread of this devastating disease.”

Firefighters in San Francisco and Chicago have been pushing for testing. IAFF Chicago Fire Fighters Local 2 at the time this article was being written was working out logistics for testing firefighters for HCV. About 30 Chicago firefighters reportedly have the disease. Union President Bill Kugelman said he tried to get city officials involved in testing the firefighters since the results of the Philadelphia Fire Department tests were made public in December 1999 but received no response.²

TESTING COSTS

Testing for HCV is a two-step process (screening and confirmation if the result is positive), according to Katherine West, BSN, MSEd, CIC, an infection-control consultant based in Manassas, Virginia. A positive screening (antibody) test must be confirmed by a second, more technically complicated test called a recombinant immunoblot assay (RIBA). Only if both are positive should an individual be told that he has tested positive. (Editor’s note: The CDC report cited incomplete testing of some of the initially reactive blood samples in Philadelphia as a factor that may have contributed to the different infection rates for the Philadelphia firefighters.)

West estimates the cost for screening at about $53. Confirmatory testing, if needed, may add an additional $175 to $200. West recommends that the testing be done by an accredited laboratory to ensure quality control.

Counseling by a qualified medical care provider is an essential part of testing, West stresses, because the testing process does not distinguish among those who are currently infected, are chronically infected, or have resolved infection. About 15 to 20 percent of persons who acquire this disease resolve their infection and have no long-term health problems, notes West. The testing process would identify those who need additional testing, counseling, and possibly medical treatment but will not yield clear information for each person tested.

A cost-effective method of testing is to institute a one-time baseline HCV screening program for current personnel and to add HCV testing to the employment physical for new hires and those who have new bloodborne exposures, recommends Thomas of Hep-C ALERT. This approach, she explains, will enable departments to identify and treat previously undiagnosed personnel and reduce or eliminate the long-term cost of care for liver disease. Annually testing previously tested personnel who did not undergo a blood or body fluid exposure on the job would not be cost- effective or necessary, she adds. The cost of health screening to identify cases of HCV in personnel in the 40 to 59 age group is equivalent to the cost associated with screening for other treatable diseases, she notes.

FILE THE PROPER REPORTS

If there is a chance that an illness or injury-HCV or some other condition-was acquired or aggravated and worsened on the job, firefighters, EMS responders, and paramedics must promptly notify their employer, preferably in writing. In many cases, the state workers’ compensation law allows an employer to forever escape its legal responsibility to affected workers if the municipality is not told of the illness or injury in a timely manner. No wages or medical benefits can be paid until notice is given. You must document all exposures to blood or body fluids, whether you think the contact was major or minor.

In most cases, the firefighter does not know at the time of rendering treatment or performing extrication whether the patient has an infectious disease, but knowing that there has been an exposure to an infectious disease is crucial for initiating prophylactic treatment and the appropriate medical care. Knowing also eliminates the stress of wondering if an exposure has occurred. To protect yourself and your family, establish a paper trail of all exposures, and keep a copy of all the documents.

Giving the employer written notice does not obligate the employee to go to court. It satisfies a mandatory legal criterion and buys the employee time to decide what should be done next. The employer cannot discriminate against an employee for claiming he has HCV, and the employer must make a reasonable accommodation for the disability.

Obviously, it is as hazardous to fail to educate firefighters about HCV and other infectious diseases, to train them in ways to prevent contracting these diseases, and to implement and follow policies that will prevent their illness as it is to neglect to train them for fire and haz-mat emergencies, to follow standard operating policies, and to implement the incident command system on the fireground.

WHAT OTHER FIRE DEPARTMENTS ARE DOING

How are fire departments approaching the HCV/infection-control issue? How much of a risk do they perceive for their departments? What actions have they taken or do they plan to take with regard to testing and prevention? Let’s look at how a few departments are handling these and other related issues.

• Cedar Hammock and Southern Manatee Fire Districts, Florida: Leigh Hollins, battalion chief. We take the threat of HCV as seriously as that of HBV and HIV. We are aware of any confirmed exposures among our members. We tested everyone for HBV several years ago and had no significant problems.

Departments must follow the exposure-control plan, use personal protective equipment, and pay attention to and know what “universal precautions” really means. It encompasses the attitude with which you approach blood and other potentially infectious materials. Most responders do not know the true meaning of universal precautions when asked. Educate them.

In accordance with the Ryan White C.A.R.E. Act, fire departments in the state of Florida are to have a designated officer for infection control. Exposures are not reported to anyone at the state operational level. The doctor who provides the counseling/testing determines how the infected firefighter should be monitored.

• Clay County (FL) Fire-Rescue: Keith Lowstetter, EMS battalion chief. The threat of HCV is greater than that of HIV. It will pose a greater threat in the future because it is not readily recognized by the patient. We just recently had our first documented exposure, which has brought the issue to light. At this time, we have no documentation of a member’s having contracted HCV. Our employees are monitored by our healthcare provider, using CDC guidelines.

We are expanding the engineered safeguards and controls with regard to protective IV needles and sharps containers that don’t have to be handheld. We are negotiating with a private contractor for consistent screening, and we have in place the protocol for reporting infectious disease exposure. Florida law provides some language for having an infectious disease considered as an on-the-job injury. [Editor’s note: Personnel who test positive for HCV will be considered occupationally exposed if they meet certain criteria in Florida’s “Presumption of Exposure” statute (112.181 F.S.), according to Thomas of Hep-C ALERT.]

We must better educate our personnel and improve communications between emergency departments and emergency medical service providers.

• Fire Department of New York: Jude Gaddis, Newsletter, July 2000, Vol. 2-No. 1, “Hepatitis C and the New York City Fire Department.” Members of the Uniformed Firefighters Association have contracted HCV; many of these cases have surfaced recently. The high number of cases reported in Philadelphia prompted a meeting between the union local’s sergeant-at-arms and the fire department’s medical officers.

We are making changes in the department’s annual physical examinations to determine if there is a disproportionate number of New York City firefighters who have contracted the virus. Baseline testing for elevated liver enzymes has always been part of the annual physical. If the liver enzyme count is high, a more definitive test can be done to see if the HCV virus has been contracted. The second test will now also be offered on a voluntary basis to anyone whose liver enzymes are normal.

The Med Mobile has been testing and will continue to test for irregular liver enzymes and will notify any members whose counts are high. At that time, more conclusive tests should be conducted to see if HCV is causing the high count.

• Jacksonville (FL) Fire Rescue. In October 2000, in conjunction with Hep-C ALERT, the department conducted a program for its firefighters, EMTs, and paramedics. The program included a one-hour education workshop that included the “Protect Yourself” training video, pamphlets, and poster produced by the IAFF and a blood test for those who volunteered to be screened for HBV. A second week of education and screening was scheduled to accommodate 300 personnel not included in the October program.
• Phoenix (AZ) Fire Department: Patrick L. Kelley, PA, Phoenix Fire Department Health Center. The City of Phoenix Fire Department provides EMS in a city of almost one million people. There is a high prevalence of HCV-positive patients in inner-city emergency departments, and our EMTs and paramedics may come in contact with blood products from these patients. Unintentional needlesticks from an HCV-positive source carry an average risk of infection of 0 to seven percent; therefore, we consider our members at risk for HCV.

We began screening for HCV antibodies using ELISA and confirming true positives with RIBA testing approximately four years ago. Intermediate and positive RIBAs were followed up with HCV-RNA testing.

With the reported prevalence of HCV in the general population at 1.8 percent, that of the Phoenix Fire Department determined by RIBA was 1.3 percent.

Some organizations recommend that healthcare providers with HCV double glove, and the CDC recommends the hepatitis A vaccine. The best way to protect firefighters from bloodborne pathogens is to use universal precautions and to appropriately dispose of contaminated needles and lancets.

Protocols are in place that mandate reporting exposures and baseline blood testing. All members are screened annually for HCV antibodies. Follow-up screening for HCV exposures is done at three to six months. Currently, there is no “policy” for granting disability leaves.

• St. Louis (MO) Fire Department Bureau of EMS: Kimberly Anderson-Wood, designated officer for infectious control, public affairs officer. The St. Louis Fire Department has been working on this topic sporadically over the past few years. Only over the past year, however, have we been able to nail down the specifics on how potential exposures should be handled operationally and financially. There are still some hurdles, including locating continued funding for HBV vaccinations for new employees and funding for 10-year antibody tests and repeated vaccination series as needed.

We adopted a standard operating procedure “Emergency Medical Operations Infectious Disease Control” in August 1995. Covered are Universal Precautions, Personal Cleaning (Field Cleaning and Engine House Washing), Isolation Techniques (Universal Precautions, Respiratory Precautions, Secretion Precautions, Contamination Precautions), and Infectious Exposure Incident (Exposure Incident, Infectious Exposure/ Contamination Form). An addendum to the SOP, designed to assist officers who may be called on to act in my absence, spells out the procedures to be followed for various scenarios involving an employee’s notification of a potentially infectious exposure, an exposure to an airborne pathogen, and an exposure to blood or body fluid (see “Bloodborne Pathogen Exposure Flowchart” on page 66).

By ordinance, St. Louis City, in 1996, has “ordained that the Department of Health and Hospitals for the City of St. Louis shall offer immunization against HBV for all law enforcement officers, firefighters, paramedics, nurses, emergency medical personnel and technicians, ambulance attendants, correctional officers, building and health inspectors, and other at-risk employees of the City of St. Louis as determined by the Health Commissioner.”

The City of St. Louis, also by ordinance, appropriated, in 1994, $173,299 “for the purpose of dealing with syphilis, AIDS, and hepatitis A, and other health-related matters.” This included funding for a crisis interventionist; two information specialists for sexually transmitted disease outreach activities; and a contract with a financial administrator for coordinating the financial aspects of the Title 1 Ryan White funds and a large cargo van for health-screening activity in the community, including syphilis, AIDS, lead, and hepatitis.

We adopted a bloodborne pathogen exposure policy in 1999. Among its provisions are that an employee who has had a “significant” exposure to a patient’s blood or body fluids receive timely treatment. An integral part of that treatment includes “tracking” the source patient in an effort to obtain laboratory testing on his blood serum for HIV and/or hepatitis. Our contracted agency does the follow-up. Tracking of a patient source costs about $100 to $165 per exposure.

• Virginia Beach Fire Department: Murrey Loflin, health and safety officer and infection control officer. Hepatitis C is a true risk to all firefighters and prehospital care personnel, regardless of their jurisdiction. The current safety and health issues generated by HCV within the fire service clearly indicate the need to revisit the infection-control issues. Each department needs to ensure that it operates under a strong and aggressive infection-control plan, regardless of the types of incidents to which it may respond. The entire issue regarding infectious disease, or communicable disease, literally “happened overnight” without much time for planning and preparation on the part of the fire service. We had to play “catch up” very quickly and address some critical issues to effectively protect our members.

OSHA Standard 1910.1030, Bloodborne Pathogens, initiated control measures to protect firefighters, emergency medical services personnel, and police officers from exposure to bloodborne pathogens. Since the inception of the infection-control process in the late 1980s and early 1990s, HBV and now HCV have been recognized as true occupational hazards. The whole issue regarding exposures to HCV and other bloodborne pathogens continues to pose a risk to firefighters as the number of citizens affected continues to grow annually. The problem is not going away. As the number of EMS incidents continues to escalate, so does the risk of an exposure. We need to ensure that all the control measures are in place and that all members understand their responsibility as well.

As with most fire departments, the Virginia Beach Fire Department initiated its infection-control program during 1989-1990. Our department is not the primary EMS agency in Virginia Beach (which is a third service). Our department worked closely with EMS and the police department to ensure that the necessary control measures were in place to safely and effectively provide prehospital care. In anticipation of an exposure, we developed procedures, which were compliant with CDC recommendations, that provide the best care possible for the member. Over the past 10 years, we refined and greatly improved these procedures.

The department experienced a nonoccupational exposure to HCV, which resulted in the death of a firefighter. Even though the exposure was a nonoccupational exposure, the outcome had quite an effect on our firefighters. Since the inception of the department’s Infection Control Exposure Control Plan in 1992, we average about two to three true exposures annually, which result in the testing and monitoring of members.

Because of the confidentiality of this issue, I do not know if any firefighter has tested positive for HCV or any other bloodborne pathogen. My responsibility was to initiate the exposure management process in case of any type of exposure, bloodborne or airborne. My responsibility primarily ended when the member was treated by the fire department physician and the infection-control nurse.

The department has made great efforts to ensure the safety and health of its members. The exposure control plan actually affects not only the fire department but also the police department, EMS, the sheriff’s office, and Parks and Recreation.

I don’t believe that the rate of transmission has been as great in the fire service has it has been with that of the public-at-large. There are exceptions to this, especially with firefighters in large metropolitan departments such as Philadelphia.

One of the problems with the data-collection process is that prehospital care workers, such as firefighters, are even included in the data analysis. The CDC monitors this process and is responsible for the data. With HCV becoming an issue in the same way as HBV is, the fire service needs to ensure that an effective monitoring process is implemented. Part of the infection-control process is to monitor the rate of transmission of HCV or any other bloodborne or airborne pathogen to members of the organization vs. that of the general public or public-at-large.

This issue is career-ending, if not life-threatening. The fire service must ensure that we take care of our own.

Each fire department has to recognize the risks associated with patient care and the hazards it generates. The fire department is responsible for ensuring that a compliant infection-control program is in place. There are many valuable resources for assisting in the development of this process. OSHA’s CFR 1910.1030 defines the components of the infection-control program and what a fire department needs to do to be compliant. NFPA 1581, Standard on Fire Department Infection Control Program, serves as a guide on how to effectively meet the infection-control requirements. NFPA 1581 is a comprehensive program that address OSHA’s requirements in a method which is comparable to our daily operations. It includes the following components: training and education; use of protective clothing and equipment; apparatus, vehicles, and equipment; standard operating procedures for safe work practices in infection control; proper methods for disposal of contaminated articles; cleaning and decontamination; health maintenance; and exposure management and medical follow-up.

Using the components of NFPA 1581 will ensure that a fire department develops a compliant infection-control program. The fire department’s health and safety officer and infection-control officer are critical for ensuring the success of the infection-control program.

In August 1992, the Virginia Beach Fire Department instituted a comprehensive exposure control plan to minimize and prevent the exposure of its members to disease-causing microorganisms transmitted through human blood, body fluids, and other potentially infectious materials. Part of this process included medical screening when there has been an exposure to a bloodborne pathogen such as HBV and HCV. When the policy was written, HCV was not as much of an issue as it is now.

Protocol requires that should there be an exposure (a specific eye, mouth, mucous membrane, nonintact skin, or parenteral contact with blood, body fluids, or other potentially; infectious materials; inhalation of airborne pathogens; or ingestion of foodborne pathogens and/or toxins), a member is to notify the health and safety officer/infection-control officer immediately so that exposure management and care can be initiated promptly.

If an occupational exposure occurs and the member must be off-duty, the leave is considered injury leave; it is not charged against the member as sick leave.

One of the problems identified early in this process is the exposure to airborne pathogens. This is very difficult to identify as an occupational exposure. The Virginia Beach Fire Department had two firefighters exposed to tuberculosis approximately 10 years ago. Their claims filed under workers’ compensation were denied because the illness could not be attributed to an exact incident on a certain date and time. Workers’ compensation in the Commonwealth of Virginia is very definitive. As part of the training and education process, members are reminded how important information gathering is during an emergency medical incident or any time patient contact is made.

We provide data relating to infectious and communicable diseases to the National Fire Protection Association; the International Association of Fire Fighters; the CDC; and the local health department, a city agency.

A member who has experienced a true exposure undergoes an initial exposure management and care process and then is scheduled to return at six-week, three-month, six-month, and 12-month intervals. The status of the source patient determines whether the member will undergo additional testing.

The exposure management process has many important components. The most obvious is to take care of the member and do as much as we can to ease the impact this process can have on the individual and his family. Confidentiality related to initial and future testing is another critical component of this program. Other key components are record keeping, returning to full-duty status, and the member’s mental well-being.

The process must ensure that no one is missed, testing is not missed or delayed, and no component of the exposure management program is left undone.

Short-term solutions are training and education. We cannot afford to become complacent with regard to communicable/infectious diseases. This is an occupational issue the fire service must face and continue addressing. An infection-control program is an excellent risk management tool for protecting members’ safety, health, and welfare.

A long-term solution would be to revisit the infection-control process on a constant basis, to ensure that the most current information and materials are included in the process. Because medical technology changes constantly, the fire service must change to remain current. Firefighters and EMS personnel must realize that the issue of communicable disease and infectious disease is not in our favor.

• Volusia County Fire Services, Deland, Florida: Captain Michael Inglett, EMT-P, RN; EMS manager. Hepatitis C is a threat, but not a great one for our department. I believe our rate of HCV infection will probably be similar to that of the national average of 1.8 percent. Most of our current staffing are personnel with fewer than eight years in the fire service, and we have had an aggressive body substance isolation (BSI)-gloves, mask, goggles, gown, or any other device that will protect an individual from exposure to bodily fluids-program since 1989. From current research studies, the higher rates of HCV in prehospital EMS are among personnel who were performing patient care before the strong push toward universal precautions, which occurred 10 to 12 years ago. These responders show approximately twice the rate of infection, even though the CDC continues to refute the research findings.

Departments that are not proactive in testing for HCV will experience a greater HCV threat in the future. Symptoms may not show for more than 20 years. That’s the reason we will be testing our entire department the middle of November (after press time).

We have had one person test positive. It was detected by the U.S. government when all Desert Storm personnel were tested on demobilization. Even though baselines had not been established and the individual had worked part time for another emergency agency, our department ended up accepting the liability based on the presumption of occupational exposure. Based on that litigation, our Risk Management Division knows we will have to cover others and, nevertheless, has agreed to have the whole department tested.

We must train our responders in BSI techniques such as the proper use and disposal of sharps and bloodborne materials and how to isolate personal wounds to prevent blood-to-blood contact. Departments should consider going to needleless systems. We are extremely proactive in this area and are protecting our firefighters: All catheters are of the retractable type, and all prefills are of the Luer port design. Since we exchange supplies with the transport agency, we have not been able to switch IV sets to a completely needleless design. We also recently switched our complete system over to nitrile gloves, which are virtually tear resistant. Also, we will no longer be contributing to the latex allergies of our personnel and patients. Within a month, we will also be using disposable cervical immobilization device systems, so we will not have to clean head pillows and recirculate them into our system, reducing the chance of exposure even more.

We began to screen all new employees this year. We are in the process of having Hep-C-ALERT come in and screen our whole department. We rescreen only if there has been a significant exposure, then we follow CDC guidelines for baseline and follow-up testing. All records are confidential, under the lock and key of the EMS manager. Records are retained 30 years post-termination of employment.

The information of a positive test is kept confidential. If we suspect that a patient may be a carrier, we contact the transporting agency and the receiving facility. If an exposure has occurred, we mandate baseline testing of patients according to the Ryan White Act guidelines. All negative test results are mailed. Positive results are handled one-on-one or by phone. Infected personnel are monitored and retested according to CDC guidelines.

Departments need to start testing now. The more departments that test, the more information we can use to influence the CDC’s position on firefighters’ HCV infection rates if the results show higher rates. This information may drive more research in the field to look for a vaccine or a cure.

States need to follow up to ensure that proper programs are in place to educate all emergency response employees (police and other agencies in addition to fire departments) on a regular basis. More states need to adopt presumptive occupational exposure legislation to protect prehospital personnel. n

Endnotes

1. “Bloodborne pathogens: compliance does matter-every call, every time,” Every Second Counts, Fall 1999.
2. The CDC’s position that first responders are not at greater risk than the general population for HCV infections and that, therefore, routine HCV testing is not warranted has led officials in some municipalities to delay decisions pertaining to union officials’ requests for implementing a firefighter testing program.

References/Selected Bibliography

• “A Hepatitis C Crisis: Firefighter Hospitalized,” Julie Knipe Brown, Philadelphia Daily News, March 2000.
• All About Hepatitis C, http://www.drkoop.com/conditions/hepatitis_c/page_45_225.asp.
• “Always on the Run: Busy Unit Seldom Has Time to Clean Up Its Equipment,” Julie Knipe Brown, Philadelphia Daily News, March 2000.
• “Among Firefighters, the Call for Testing Is Now Nationwide,” Jennifer Lin, Philadelphia Inquirer, Jan. 27, 2000.
• An Open Letter to All Firefighters and Paramedics, Hepatitis C-“The Silent Killer,” Strikes Hard on Members of the Fire Service, May 8, 2000, George T. Casey, president Local 22 IAFF, http://www.local22iaff.org/html/CaseyLetter.htm.
• The Blood Samples Act: Bill C-244 The Right to Know, http://www.iaff.org/ iaff/GovAff/html/fact_6.html.
• Bloodborne Pathogens: Reality Check, http://www.iaff.org/iaff/Health_Safety/ Redmond/Online_Coverage/hepatitis_c.html.
  • “Hepatitis C and the New York City Fire Department,” Jude Gaddis, Uniformed Firefighters Association of Greater New York, Local 94 IAFF, AFL-CIO, New York, NY, newsletter 2:1, July 2000.
  • “Hepatitis C Is Deadly: Many Emergency Workers Around Country Afraid to Be Tested or Treated,” Julie Knipe Brown, Philadelphia Daily News, Mar. 2000.
  • “Hepatitis C Virus Infection Among Firefighters, Emergency Medical Technicians, and Paramedics-Selected Locations, United States, 1991-2000,” Centers for Disease Control and Prevention, MWWR, July 28, 2000/49(29);660-5.
  • “Hepatitis C Was Killing Me Until Alternative Medicine Did What Conventional Medicine Could Not ellipse” Sherril J. Wolff, http://botanical.com/botanical/article/hep-c.html/. Note: This resource is presented here not as an endorsement of any particular substance, protocol, or therapy but as a source of information for individuals with hepatitis C who may want to gather as much information as possible to discuss with their healthcare provider.
  • Hep-C-ALERT, press release, Nov. 16, 1999.
  • “Hep-C ALERT Extends Hepatitis C Research Study to Jacksonville Fire Rescue,” http://www.hep-c-alert.org/about/press36.html.
  • “Lawmakers Introduce Needlestick Safety Bill,” Todd Zwillich, Washington Reuters Health, Sept. 2000.
  • “Needlestick Injuries,” http://www.oshaslc.gov/ SLTC/ needlestick/index.html.
  • “PA State Treasurer Joins Firefighters in Hepatitis C Awareness March,” Aug. 3, 1999; PR Newswire, http://www.firehouse.com/news/2000/8/3_philly_ main.html.
  • “Philly Firefighters Fired Up ellipse,” Dana DiFilippo, Philadelphia Daily News, July 7, 2000.
  • “Quietly Doing the Right Thing,” Andi Thomas, Hep-C ALERT, Inc. founder and executive director, On Scene, IAFC, Oct. 1, 2000.
  • “Sounding the Alarm,” Julian Walker, TIMES NEWSPAPERS, August 9, 2000, 5.
  • “The Washington Report, Excerpts from Hepatitis C Consensus Conference,” Hepatitis Foundation International, April 1997, http://www.hepfi.org/s97insert.htm.
  • “Why Has Hepatitis C Infected 130 City Firefighters? THE BURNING QUESTION,” Julie Knipe Brown, Philadelphia Daily News, Jan. 10, 2000, 3-7.

  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.