"A Truly Unappreciated Field Of Endeavor"

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Being a Clint Eastwood movie fan and a military history buff, I am delighted when Eastwood makes a military movie. One such movie is "Heartbreak Ridge," in which Eastwood portrays an aging Marine sergeant who fought in Korea and Vietnam. Longing for more action, he maneuvers himself back from a warehouse job to a position as sergeant in a reconnaissance platoon.

After arriving at his new military base and assignment, he finds himself at odds with the major of the company, a much younger man. In one early scene, during their first encounter and introduction to each other, Eastwood finds himself in the room with the younger major and the sergeant major of the company, who also fought with Eastwood's character in Korea and Vietnam.

While Eastwood stands at attention in front of the major as he reviews Eastwood's military record, the major says, "I have not yet had the privilege of battle. I came over recently from supply and logistics." The sergeant major, in a very patronizing and somewhat sarcastic tone, says, "A truly unappreciated field of endeavor, sir."

How true this must have felt for the members of the Philadelphia Fire Department and everyone in the fire service when the federal Centers for Disease Control and Prevention (CDC) came out with a report this past July that says rescue workers are not at greater risk than other workers of contracting the hepatitis C virus (HCV) as a result of the work they perform. In essence, the CDC concluded that hepatitis C was not a work-related risk for so-called "first responders" - firefighters, paramedics and emergency medical technicians.

Tell that to members of the Philadelphia Fire Department and other clusters of infected fire service personnel who have contracted hepatitis C. As of this writing, 152 members of the Philadelphia Fire Department and countless other fire service professionals around the United States have tested positive for hepatitis C. Most of those who have tested positive are veterans of the fire service and have 20-plus years of experience.

The CDC study looked at the infection rate among fire service and EMS professionals in Philadelphia, Atlanta, Pittsburgh, Miami-Dade County and various parts of Connecticut. Even though the CDC study showed that those in the fire service have an infection rate twice that of the national average, the agency still contends that professionals in the fire service should not be compared with the overall public.

The CDC argues that men of a certain age group in the fire service should not be compared to everyone. Instead, men of a certain age group should be compared with other men in the same age group. The CDC contends that when those comparisons occur, there is no higher incidence of hepatitis C in the departments studied than in the general population.

Additionally, the CDC asserts that the virus is most often transmitted through contaminated needles shared by intravenous drug users or through high-risk sexual activity. Hepatitis C was also passed on through blood transfusions prior to 1992, when screening for the virus became available.

Obviously, people at CDC have been staring at their culture dishes too long. In early August, I was invited to speak at a combined conference of EMS professionals, nurses and physicians. In between my own lectures, I stopped in to listen to a lecture on hepatitis C. The lecturer was a nurse who was the mother of three children. Her lecture began slowly. She used no audiovisuals and she virtually read her lecture from notes. Early in her presentation, I was trying to figure some way of sneaking out of the room, since this was looking to be a terrible lecture.

Soon, though, I became riveted to my seat as she painstakingly walked her audience through her ordeal after accidentally getting stuck with a needle in the emergency room from a person who was unaware of being infected with hepatitis C. Her sometimes interrupted and tearful and emotional talk permeated the silence in the room as she, in detail, described her terrible pain, the strain on her marriage, financial difficulties, disappointing medical therapies, the future of a possible liver transport and ultimately what may lead to her death. At times, I looked around the room and saw tears streaming down the faces of others listening to her story.

Ironically, the CDC includes this woman in its "health-care worker" category as someone who is also not at risk to contract hepatitis C. It seems to me that a logical person could conclude that anyone who comes in contact with blood and body fluids on an almost daily basis is certainly at higher risk than the general population. I would certainly consider this nurse at higher risk than a construction worker or a secretary in an office - assuming all three persons did not have lifestyles (drugs, promiscuous sex, etc.) that put them at high risk.

Anyone who closely examines the methodology by which the CDC concluded that those in the fire service are not at risk for contracting hepatitis C would see it is flawed.

First, data and serum from some geographic areas that were used were almost 10 years old. For example, data was used from 1991 Atlanta and 1992 Connecticut studies. In the Atlanta case, stored serum for a 1991 test for hepatitis B from voluntary and anonymous metropolitan Atlanta uniformed fire personnel was tested in May 2000. The CDC concluded there was no significant difference in those who tested positive for hepatitis C than non-fire service personnel in the same age category. In the Atlanta study, no consideration was given for a uniformed fire service person's years of service. Many of those presently testing positive for hepatitis C were in the fire service before the use of universal precautions became important.

The same illogical approach used by the CDC in the Atlanta data was also used in the Connecticut sampling. Stored serum samples from various first responders in Connecticut that were used to test for hepatitis B in 1992 were pulled off the shelf and retested in June 2000 for hepatitis C. Again, the CDC concluded the numbers were not high and were in line with those recorded among non-fire service personnel in the same age group who had hepatitis C. Again, this data is skewed, since no consideration is given to those with longer tenure or job assignments in the fire service.

The CDC concluded its report by saying, "Among first responders, HCV infection was associated primarily with nonoccupational factors." In essence, the report from the CDC is too limited and never took into consideration veterans of the fire service who some 20 years ago did not have the luxury of knowing to protect themselves by wearing gloves, gowns and goggles.

In response to the CDC report, over 1,000 firefighters from across the country conducted a "Hepatitis C Awareness March" and rally on the last day of the Republican National Convention in Philadelphia in July. A doctor from the American Liver Foundation, elected officials and several members of the Philadelphia Fire Department who have contracted hepatitis C delivered speeches. The purpose of the march was to focus attention on hepatitis C and the threat it poses to those who work in the fire service. I hope it never happens, but if a fire professional dies on the job from a wall collapse or hepatitis C, both are recorded as line-of-duty deaths.

Certainly, as the CDC number crunchers sit in their spotless white lab coats and in a healthy clean environment, it is clear to them that working in the fire service is "a truly unappreciated field of endeavor."


Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief paramedic for the St. Louis Fire Department and is the vice chairman of the EMS Executive Board for the International Association of Fire Chiefs. He has lectured nationally and internationally on fire-based EMS topics and operates The Ludwig Group, a consulting firm specializing in EMS and fire issues. He can be reached at GaryLudwig@aol.com.

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