Hepatitis C Virus

By Deborah Owen, M.d., Medical Director, SFFD

I had the honor and privilege of sitting next to Firefighter/Paramedic Mary Kohler on a panel discussion about hepatitis C for Fire Engineering’s 2001 Fire Instructors Conference in Indianapolis, Indiana. Mary has hepatitis C (HCV) and is fighting for her life. She is also fighting the City of Philadelphia in an attempt to get her disease accepted as work-related. Mary clearly had none of the usual risk factors associated with non-occupationally acquired HCV. She had no history of blood transfusions (transfusions prior to 1992 are considered a risk factor), she never used IV drugs (even one experience with IV drugs is considered a risk factor) and she never required hemodialysis.

What she did do is respond to emergencies as a paramedic for the City of Brotherly Love for 10 years. Hepatitis C has taken its toll on her and she no longer has the energy it takes for emergency response. Acknowledging that she can no longer perform the duties of her job was one of the most difficult decisions she ever had to make. Her job defined her— a dedicated worker who was ready and able to respond to those in need. Now she cannot respond and the city she so dedicatedly served refuses to take responsibility.

California firefighters are fortunate that a presumptive law exists which may spare them the stress of fighting to have hepatitis C considered work related. Section 3212.8 of the Labor Code was approved on September 16, 2000. This law provides that hepatitis is a presumptive disease for firefighters and law enforcement personnel. However, the statute is limited in that the presumption ends five years after members have terminated employment. Hepatitis C may not become clinically apparent for 10 - 40 years—long after a firefighter or paramedic may cease active employment. The only certain way to know if you have been exposed is to test for antibody against hepatitis C.

The most common screening test is an EIA or ELISA test which tests for antibody to HCV. This stands for enzyme immunoassay or enzyme-linked immunoabsorbant test. The test is good but does carry a risk of testing falsely positive. A confirmation test is typically performed with a hepatitis C virus reverse transcription polymerase chain reaction or RT-PCR. This test actually tests for hepatitis C virus RNA. If this test is positive you have the virus. If the RT-PCR is negative, you must still get a confirmatory test with a recombinant immunoblot assay or RIBA. If this test is negative, you do not have hepatitis C. If this test is positive, you have been exposed to hepatitis C but have cleared the infection.

Approximately 15% of people who contract HCV are able to mount a sufficient immune response to clear it. For the vast majority the disease is clinically quiet. Unfortunately, liver damage can be occurring during this time. The potential for worsening liver disease that is severe and life threatening may occur in up to 30% of those infected. Given the paucity of symptoms in the majority of those infected with HCV, it is understandable that many infected people are unaware that they have the virus.

Routine testing is currently recommended for the following groups:

• Anyone who ever injected illegal intravenous drugs

• Anyone who received blood products prior to 1992

• Anyone on long-term hemodialysis

• Healthcare workers who have sustained needlestick, sharp, or mucous membrane exposures to HCV- positive blood

• Children born to HCV-positive women

Any firefighter or paramedic who is exposed to blood through needlesticks, sharps or mucous membranes will be tested at San Francisco General Hospital’s Occupational Health Clinic. HCV transmission in the healthcare setting appears to be related to accidental needlesticks. The mechanism of exposure for the majority of SFFD members appears to be through mucous membranes. During FY99-00 the following exposures were reported through SFGH OHC: Needlesticks – 5, Mucous membrane exposures – 12, Non-intact skin – 3 and Bites – 2. Firefighters and paramedics who are concerned about past exposures should contact me to discuss testing procedures (558-3447).

If you do have hepatitis C it is extremely important to do everything you can to take care of your liver. Alcohol is toxic to the liver and should be avoided. Hepatitis A and B can have severe clinical courses in those already infected with HCV. Those who haven’t already been vaccinated against hepatitis A and B should get these vaccines. Regular follow-up with your medical doctor to monitor liver enzymes and assess the need for therapy is vitally important. There are new formulations of existing therapies that improve the chances of clearing the virus. These medications are not easily tolerated and the decision about therapy must be individualized for each patient.

The major goal regarding hepatitis C infection is certainly disease prevention. A vaccine is not on the immediate horizon because of HCV’s ability to quickly mutate. Also, the only model for infection besides humans is the chimpanzee which is difficult to use in the laboratory because of its endangered species status. But research into a vaccine for HCV still continues and will eventually become a reality. In the meantime, practicing universal precautions is essential as is keeping abreast of the latest developments in safe supplies (such as needleless systems). Reducing the risk of exposures will help to keep firefighters and paramedics from having to deal with the dread of this disease.


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