THE OSHA HEARIHGS: Testimony of Clyde Bragdon, Jr.
LAWS & LEGISLATION
IN SEPTEMBER AND October of this year, the U.S. Department of Labor Occupational Safety and Health Administration held rulemaking hearings on proposed 29CFR 1910.1030, “Occupational Exposure to BloodBorne Pathogens.” The proposed regulation would help protect healthcare workers and all emergency first responders from exposure to Hepatitis B, AIDS, and other diseases transmitted through the blood. (For a summary of the proposal, see “Proposed OSHA Regulation Protects Against Blood-Borne Viruses” by Matthew E. Siniarski in the September ’89 issue of Fire Engineering.) The following is the testimony of Clyde Bragdon, fr., administrator of the US. Fire Administration:
As USFA administrator, I am testifying on behalf of the nation’s volunteer and career firefighters and the emergency medical technicians and paramedics who staff the fire services. Many of the nation’s firefighters are cross-trained and certified as EMTs and paramedics, whereas some emergency medical technicians and paramedics are part of a separate third service. These workers will all benefit from the passage of OSHA’s proposed rule. They all need protection as much as—if not more than—anyone else, and this is a substantial enough group of emergency professionals to warrant mandatory protection. . . .
Charged by Public Law 93-498, the Federal Fire Prevention and Control Act, the USFA is the leading federal agency in addressing the nation’s fire problems, including firefighter health and safety issues. In order for the USFA to do its job accurately and efficiently, we must maintain accurate and complete data on fire service personnel and update it on a regular basis. USFA is equipped to collect this data and is recognized as the official government source of data on fire incidence in this nation and its effect on fire service personnel.
My concern is that the statistics on fire service personnel included in the proposed rule are inaccurate; therefore, they cannot possibly reflect the true need for mandatory protection. The proposed rule states that there are 3,174 fire and rescue department facilities. USFA data documents more than 10 times the OSHA estimate—not in terms of facilities but rather by fire departments, some of which may have many facilities. There are actually more than 34,000 fire departments across the country. Similarly, the proposed rulerecords 201,749 fire and rescue personnel, a very precise but exceedingly inaccurate number. USFA data documents that there are more than 1.2 million firefighters serving this nation. These major discrepancies in OSHA’s figures indicate that OSHA is perhaps only citing the numbers of facilities and personnel covered under its regulations. The documentary evidence that we are presenting delineates the potential number of firefighters who could be affected by the Final Rule.
When looking at the recent data from USFA, the need for mandatory protection becomes much more apparent. Far more people than the proposed rule indicates risk their health through exposure to infectious diseases. The large numbers of personnel at risk magnify the need for protection from, and education about, blood-borne pathogens.
The fire service is unique in its makeup of both career and volunteer firefighters. There are also public, private, and volunteer ambulance companies for which the USFA has no statistics. Because only 23 states have OSHA-approved occupational safety and health plans, and because some of these may not cover volunteers, not all firefighters, EMTs, and paramedics are covered under OSHA regulations. We believe that the Final Rule could benefit all fire service personnel.
Today’s firefighter is not just a firefighter. He is also an emergency healthcare worker, often the first to arrive at the scene of an accident. In fact, 80 percent of all field emergency medical care is provided by the fire service. The occupational exposures inherent to their jobs necessitate that the proposed rule cover all firefighters, EMTs, and paramedics. Although not officially classified as healthcare workers, these fire and rescue personnel consistently face the potential for being exposed to direct mucous or skin contact with infected blood, body fluids, or tissues. This potential puts them in “Category One” —their job requires the risk, and they knowingly assume that risk in order to save lives. In return for their service, it is our duty to provide them with an assurance of safe working conditions and the best information available to keep them from being unnecessarily exposed to physical danger. By ensuring that the Final Rule includes all fire and rescue service personnel, the risks they face on the job will be minimized.
Fire and rescue personnel often come into contact with infectious diseases through routine channels. Many unique circumstances present personnel with the risk of contracting blood-borne diseases. In addition to the routine medical emergencies, automobile accidents, and rescues that firefighters, EMTs, and paramedics respond to, there are numerous other situations unique to these professions where there is a strong potential for occupational exposure to blood-borne diseases.
One example of such a circumstance involved a volunteer fire and rescue department protecting a college town in the eastern United States. The first unit to arrive at a house fire in the middle of the night was an ambulance with three firefighter/EMTs. One victim was lying in the front yard after jumping out of a second-story window. He was unresponsive and bleeding from numerous lacerations. The firefighter/EMTs began immediate care, including cardiopulmonary resuscitation, as they kneeled and worked in and around the broken glass. In the performance of their duty, they risked being lacerated and having contact with the victims’ bodily fluids. Meanwhile, other firefighters arrived and, upon searching the burning house for other people who may have been trapped, found a second victim who was not breathing. By the light of a hand-held flashlight, the firefighters carried the victim to the front porch; removed their own helmets, selfcontained breathing apparatus, and gloves; and began CPR. When mouth-tomouth resuscitation was initiated, the victim immediately vomited, spraying the firefighter giving mouth-to-mouth and covering the firefighters’ work area with vomitus.
Neither of the two victims of this fire survived. Both were college students and were reported to be “sexually active around campus”; however, both sets of parents refused to allow postmortem testing for infectious diseases. Thus, the firefighters and firefighter EMTs had an extreme risk of an occupational exposure to blood and other body fluids yet had no way of determining what, if any, disease they were exposed to.
Other circumstances unique to today’s society also increase the danger to fire and rescue personnel. Intravenous drug users who share needles have a high possibility of carrying the Human Immunodeficiency Virus that causes AIDS. These people often live in lowincome urban areas or on the streets. The poor are statistically one of the major high-risk fire populations. Thus, IV drug users are at an increased risk for being both fire victims and carrying blood-borne disease. Unfortunately for fire and rescue personnel, it is often these individuals who need to be rescued; consequently, emergency rescue workers face an invisible enemy in their battle to save fire victims.
Such is the case in Newark, New Jersey, where 50 to 60 percent of the known IV drug users tested have been found to be HIV-positive, according to Dr. David V. Barillo, who works with the Newark Fire Department. Dr. Barillo describes a case where a fire captain was searching the fifth floor of an apartment building known to be occupied by IV drug users. The captain was in dense smoke, looking for victims trapped by a fire on the floor below. Crawling on his hands and knees, he reached out to feel for victims and stuck his hand in “something wet and gooey.” It turned out to be a dead body, charred and split open from being burnt by the fire. The captain’s glove and arm were soaked with body fluids, and the fluid had leaked over the floor where he was kneeling. Although he was wearing full protective gear for structural firefighting, he now had body fluids soaking through his glove and contaminating the rest of this protective clothing.
This circumstance happens with greater frequency to firefighters than to others—to unexpectedly find a body and related body fluids. A similar occurrence last winter in Fairfax County, Virginia, had firefighters responding to what was believed to be a pile of burning trash but was instead a blazing makeshift shack where several homeless people were living and trying to keep warm. All of the occupants suffered severe burns. Since paramedics are not automatically dispatched on calls for trash fires, firefighters pulled the victims out and provided medical care until the paramedics arrived. All of the victims were later tested and found to be HIV-positive, and all of the firefighters were exposed to foreign body fluids during the rescue.
In today’s society, almost any fire department may be called upon to battle a fire in a so-called “crack house” or “shooting gallery.” Right here in our nation’s capital, firefighters in only one day fought major blazes in five such buildings after a vigilante allegedly tried to bum out the drug users. One of the problems facing these firefighters is that they must crawl on their hands and knees through the dense smoke to the fire—crawling, that is, over used or dirty hypodermic needles and other discarded sharp drug paraphernalia. As we are all aware, IV drug users are one of the leading risk groups for the spread of HIV and Hepatitis B, and being stuck by an infected needle in these circumstances is a new and unique situation for firefighters.
These are not the only situations in which firefighters run the risk of exposure to infectious disease. For example, there is the overturned car at the bottom of the ravine, the inside of a tank under repair, the scaffold outside of a building 30-stories high, or the middle of an interstate highway. Anywhere people can become injured or ill, firefighters, EMTs, and paramedics run the risk of an occupational exposure to infectious disease. As first responders to these medical emergencies, they provide initial care and relay vital information to other healthcare providers such as physicians and nurses. These fire service personnel must be provided with the same protection as every other healthcare provider.
Many of these types of exposures I have mentioned are unique to firefighters and firefighter/EMTs, and such risks can only be addressed by adequate training and education for firefighters; mandatory requirements for fire departments to provide personal protective equipment such as gloves, fluid-resistant clothing, and eye protection; and the requirements for firefighters, EMTs, and paramedics to use personal protective equipment, including ventilation devices, every time emergency care is given.
Another protective measure of concern to OSHA relates to the covering of open or unprotected skin. We recommend that, prior to any contact with patients, firefighters, EMTs, and paramedics cover with adhesive dressings all areas of abraded, lacerated, chapped, irritated, or otherwise damaged skin. Additionally, personnel with lesions or areas of severe dermatitis on the head, arms, hands, face, and neck should refrain from direct patient contact, from handling patient care equipment, and from handling medical waste. These areas of the body are generally uncovered and are most at risk of contamination. By preventing contact with open or damaged skin, a fire or rescue worker will reduce his risk of exposure to contaminated blood and body fluids. Patient care equipment is also included because it too can become contaminated and, after coming in contact with damaged skin, can contaminate the worker.
To help prevent the contraction of Hepatitis B, a major infectious disease, vaccinations should be made available to all healthcare workers, especially firefighters, EMTs, and paramedics. However, the administration of these vaccinations should not be contingent upon the frequency of possible exposure to an infectious disease.
It only takes one exposure to contaminate an individual. This is especially applicable to fire and rescue personnel who operate in uncontrolled, often hostile conditions. Many healthcare workers operate in a controlled environment, such as a laboratory or hospital. In contrast, fire and rescue workers have to deal with burning buildings, irate crowds, traffic, hazardous materials, and other uncontrolled and dangerous situations. Anything can happen while in an emergency situation, including having to handle potentially infected people and contaminated equipment.
Vaccinations help protect fire and rescue personnel from contracting Hepatitis B, and several successful vaccination programs have been implemented in Seattle, Washington; Phoenix, Arizona; Jacksonville, Florida; Fairfax County, Virginia; and the state of Rhode Island.
The Los Angeles County Fire Department recently implemented a Hepatitis B vaccination program for more than 1,800 employees on three shifts. Using a private contractor, their plan was to immunize all employees in the 2,200square-mile jurisdiction in only nine days, with no interruption of service to the citizens or additional costs to personnel. According to Marguarite Jordan of that department, the program’s cost is more than justified by the level of protection it offers the employees, as compensation costs would be much greater were exposures to occur to unprotected personnel.
Other methods considered for administering this program were via the county health centers, the nurses’ registry, and a self-administration program in which department paramedics give coworkers the vaccine. (The latter was found to be unlawful in California, although it has been both lawful and successful elsewhere.) While there are several methods of administering such a program, the simple fact that 1,800 firefighters on three shifts located in a 2,200-square-mile area could be immunized in a nine-day period is proof that any fire department can set up a successful vaccination program. It is our contention that all fire departments and EMS agencies should follow this lead.
It is imperative that an established Hepatitis B vaccination program be made available to all firefighters, EMTs, and paramedics at no cost to them. As recommended at the first USFA forum, healthcare workers should be provided with all current preventive measures for infectious diseases. According to OSHA’s General Duty Clause, the employer is responsible for providing “safe and healthful working conditions.” The Department of Labor/Department of Health and Human Services Joint Advisory Notice “Protection Against Occupational Exposure to Hepatitis B and HIV” states that the employer should make available voluntary HBV immunization for all employees who perform Category One tasks at no cost to the worker.
With the caveat that prevention is more desirable and cost effective than treatment and compensation, along with an awareness of the unusually high prevalence of Hepatitis B among those in the fire service, we feel that vaccination programs should be mandated in OSHA’s Final Rule. This activity should proceed with the understanding that legally no individual should be mandated or required by any organization (employer or union) to receive said measure without being given either the option of informed consent and/or informed rejection.
The U.S. Fire Administration is committed to increasing firefighter safety from occupational exposure to infectious diseases. All of the USFA’s major infectious disease initiatives to date have specifically addressed fire and rescue personnel and have included the participation of emergency medical, infection control, and legal experts; fire service professionals; and allied federal agencies sharing information, exploring dominant issues, and making recommendations.
The U.S. Fire Administration supports OSHA initiatives that actively address firefighter health and safety problems.