JENNIFER LIN
Reprinted with Permission, Philadelphia Inquirer
Firefighters across the country are scrambling to find out whether the hepatitis C crisis in Philadelphia is a problem they face as well.
Philadelphia firefighters have three times the national infection rate for the virus that causes hepatitis C, a disease more prevalent than AIDS and so destructive that 15 percent of patients will suffer liver failure, requiring transplants.
"We realize today it's them, tomorrow it could be us," said Keith Kemery, a firefighter in Gloucester Township.
Firefighters in San Francisco and Chicago are pushing for testing, and those in Miami and Honolulu already have testing plans. Even the small fire and rescue squad in Brigantine, N.J., has bought 33 test kits.
Coming to their aid, U.S. Rep. Robert A. Brady (D., Phila.) last week proposed spending $10 million for national testing of firefighters. The virus for hepatitis C is transmitted by blood and can be detected through a simple blood test, available at drugstores.
About half of the 4,400 active and retired firefighters in Philadelphia have been tested confidentially for the hepatitis C virus. Of those, 6 percent tested positive. Among the public, the infection rate is 1.8 percent of the population, according to the federal Centers for Disease Control and Prevention.
What's more, the disease is hitting veterans of the department hardest. Philadelphia firefighters ages 50 to 59 have an infection rate that is four times the national average for men in the same age group. For local firefighters in their 40s, the incidence rate is nearly double the national rate for men that age, according to statistics provided by the Home Access Health Corp. of Chicago, which tested Philadelphia firefighters last fall.
If untreated, the hepatitis C virus can lead to cirrhosis, advancing to liver failure or liver cancer.
"There's panic," said George Casey, president of Local 22 of the Philadelphia Fire Fighters' Union.
Firefighters fear that they run a greater risk of contracting the disease because of the changing nature of their work. In many cities, including Philadelphia, firefighters do more than put out fires. Locally, three out of four calls are for emergency medical rescues that put firefighters in direct contact with blood - the chief medium for transmitting the hepatitis C virus.
Many suburban fire departments, such as those in South Jersey, also handle rescue work. But in the Pennsylvania suburbs, most fire services respond only to fires, leaving emergency medical calls to hospitals.
Some medical experts doubt that firefighters run a greater risk of contracting hepatitis C on the job. The most common cause of infection is through intravenous drug use.
But the local union rejects that explanation, saying it cannot account for the alarmingly high infection rate. It argues that the constant exposure to blood in uncontrolled situations is a more logical cause.
"We're the first ones on the scene, so it's not similar to health-care workers," Casey said. "Doctors look like astronauts today. But sometimes we have to rescue people from auto wrecks. You have to take off your helmet, your coat, your mask to get under a car to help them."
Only about two dozen of the 132 local firefighters with the virus have notified the department or the union. Casey said many are afraid doing so will hurt their careers. Others fear the stigma that this is a drug user's disease.
Casey has heard enough stories to know that this crisis is worse than any other.
He has seen families exhaust savings and use credit cards to buy the only drug therapy - a combination of interferon and ribavirin that costs $17,650 for a year's supply.
He has witnessed the shock of firefighters like 37-year-old Mary Kohler, who has seen her love for rescue work eclipsed by a fear that someone she helped made her sick.
And he has prayed for victims like Kevin Myers, 51, who is so stricken by liver failure that he lies on the sofa waiting for the hospital to call with news of a liver donor.
Overnight, Casey, 53, has become an expert on the disease. He spends hours at home scanning Web sites for information and highlights passages with a yellow marker as he pores over medical texts.
One of the people to call him was Greg Matney, a 55-year-old Honolulu firefighter who needs a new liver. He told Casey that the Honolulu Fire Department had stymied his earlier efforts to get fellow firefighters screened for the virus. But the news in Philadelphia changed attitudes overnight. This week, the Honolulu department started making plans to test all 1,129 firefighters.
"Everyone jumped and started changing all their thinking on dealing with hepatitis C," Matney said.
Testing for hepatitis C is critical because symptoms can take 10 to 30 years to develop. That's why former U.S. Surgeon General C. Everett Koop dubbed the disease "a silent epidemic." Few people even know they are infected, even though an estimated 4 million Americans test positive for the hepatitis C virus.
Unlike hepatitis B, there is no vaccination for hepatitis C and it typically is a chronic condition that attacks the liver over a longer period. Before blood banks screened for the hepatitis C virus, it was transmitted via blood transfusions. The virus also can be spread by sharing needles, or coming into contact with tainted blood from tattoos, body piercing or sexual activity.
Since the AIDS crisis came to light in the mid-1980s, firefighters have known about the dangers of blood-borne diseases. But until a decade ago, many of them took a lax approach to precautions. Firefighters, especially the paramedics on the force, wore blood on their uniforms like a badge of honor.
Today, they know better.
Not long ago, George Casey was off duty when he came across a woman who had cut her forehead after falling on ice.
"I hesitated," said Casey, a 32-year veteran firefighter. "For the first time in my life, I actually hesitated."
Mary Kohler is No. 132 - the latest firefighter to test positive for the hepatitis C virus.
"It's very scary to get the paperwork in the mail that tells you how to ask about medical coverage for a liver transplant," said Kohler, whose husband, Bill, is a former city firefighter. They live in the Northeast.
Kohler talks about her work as a calling. Her hometown of Nahunta, Ga., was so small there wasn't a hospital for 30 miles. The funeral director used his hearse for emergency runs to the hospital. When the town got its first emergency rescue squad, Kohler was entranced.
"They were my heroes," said Kohler, a paramedic for 11 years and the department's first female lieutenant.
Now, not a moment goes by when she doesn't wonder who gave her the disease.
Was it the newborn delivered by a middle-aged woman into a toilet bowl? All Kohler could see were the baby's buttocks. She pulled the child out, cut the umbilical cord and put her lips over the baby's mouth and nose, never stopping to wonder about the blood on the baby, never stopping to put on gloves.
"We don't think that way," she said. "We have a duty to act and for the most part nothing gets in our way."
Kohler said that when she joined the department, latex gloves were available in only one size - men's. They slipped off her hands and made her fumble with instruments. In the cold, they cracked.
"Hepatitis C was never a subject we discussed. Never were we trained about it," said Kohler, who was a paramedic instructor at the Philadelphia Fire Academy before taking a job at headquarters.
Today, firefighters wear better gloves that resist punctures. They are equipped with goggles and special masks to put on victims before administering mouth-to-mouth resuscitation. They approach every victim as a potential carrier of disease.
"There was a time we wouldn't fear children," said Bill Kohler. "It wasn't even a thought. A child could never hurt you. Now we know it's not true."
Mary Kohler went public as soon as she found out she was infected with the virus. "I have nothing to be ashamed of," she said. "I know I never used drugs. I've never had a transfusion. I've never been promiscuous. There is no other place that I could have gotten it than doing my job."
If Kohler started to develop symptoms, she would have to prove to the city that she contracted the disease on the job in order to qualify for workers' compensation. The union is lobbying Harrisburg lawmakers to extend automatic coverage for hepatitis C to firefighters, as it has to other emergency care workers.
Miriam Alter, a CDC epidemiologist, said a majority of hepatitis C infections are from lifestyle risk factors, rather than occupational risks. Although the CDC has not studied firefighters, she said it has looked at health-care workers as an overall group.
"We've studied hepatitis C among health-care workers with frequent exposure to blood, such as orthopedic surgeons," Atler said. "They do not have elevated rates of hepatitis C.
"Therefore, even though the firefighters are first on the scene and exposed to blood in uncontrolled situations, it is likely that a majority of their infections are due to non-occupational risk factors," she said.
In addition, she said that studies of hepatitis B, another blood-borne disease, have shown that a majority of infections among so-called first responders such as firefighters and paramedics came from non-occupational risk factors.
Only a few cities - Phoenix, Tucson, Portland, Ore., and a handful of towns in Florida - have screened firefighters for the hepatitis C virus. In each case, the infection rate was close to the national average.
But several medical and public health experts argue that it would be a mistake to dismiss the problem in Philadelphia. They said that a nationwide survey is necessary to determine whether Philadelphia is an anomaly or the norm.
"These are staggering numbers," said Alan Brownstein, president of the American Liver Foundation. "It's important for the awareness of hepatitis C and for firefighters in Philadelphia not to trivialize this."
For Kevin Myers, the debate over how firefighters are infected is meaningless. He faces a bigger dilemma: He will die unless he gets a new liver.
He is embarrassed to let his friends see him nowadays and spends all his time at home in Southwest Philadelphia. He has lost 65 pounds. He looks 70 rather than 51. His belly is distended. His liver no longer functions. So much ammonia builds up in his system that thinking clearly is difficult for him.
"I'm convinced I got it on the job," said Myers, too weak to talk much. "If only a couple of people had it, that would be different. But 132?"
When he retired in 1996, he was diagnosed with cirrhosis, a severe scarring and obstruction of the liver. Even though he was under a doctor's care for hernia problems, he was not tested for hepatitis C until the union called everyone in for testing in November. His test came back positive.
His wife is angry and afraid. "The guys he went to fire school with haven't been tested yet and it bothers him," Shirley Myers said.
If her husband had been tested years ago, she said, "maybe he wouldn't be going through this today."
