First Responders and the Silent Killers

In the dangerous world of law enforcement, a peace officer's exposure to human bodily fluids and fluid-related infections is not typically discussed as a topic of officer safety. Unlike the obvious danger of being assaulted, the risks of blood-borne infections are silent with virtually no recognizable warning signs. As potentially life-threatening as any violent encounter, certain contagious infections have significant adverse consequences, which can extend to an individual’s family health, as well as the fitness to continue a career in law enforcement. Peace officers dedicate the majority of their time preparing for an immediate violent threat. Firearms training, defensive tactics and the wearing of body armor all play major roles in crisis preparation. In the presence of these modern silent killers, it’s important to recognize the risks associated with body-fluid exposure and to pursue the education, planning and prevention of exposure and transmission of these diseases.

 

The Centers for Disease Control and Prevention (CDC) estimates that more than one million people are infected with the Human Immunodeficiency Virus (HIV) in the United States.¹ It is estimated that 1.2 million individuals are infected with the Hepatitis B virus and 3.2 million are infected with the Hepatitis C virus.^2,3 All three of these viral infections will lead to death. The majority of infected individuals do not show outward signs of their disease and may be unaware of their contagious risk. Regardless of the situation, age or sex of an individual, the universal precaution protocol should be followed with any contact in the field.⁴ The route of work-related transmission of HIV, Hepatitis B and Hepatitis C to a peace officer is identical to any other first responder or health care provider.^5,6 Exposure to bodily fluids, especially blood through an open wound, eye contact, needle sticks or a human bite, are the most common pathways for infectious transmission.^5,6 Research about the relative risk of law enforcement officers being infected after an exposure is not well defined and minimal in comparison to the amount of research directed toward health care workers and their related risk.

 

The backbone of all law enforcement operations entails planning and prevention on a daily basis. As with U.S. health care protocol, the use of universal precautions should be standard operating procedure within law enforcement.⁴ Although federal safety mandate requires every law enforcement agency to supply gloves and eye protection in every patrol car, comprehensive officer safety does not stop at federal law or OHSA requirements.^7,8 Peace officers should make every effort to follow a daily routine of precaution and proactiveness. This should include covering all wounds or scratches with a waterproof dressing prior to dressing in uniform. Beginning each shift wiping down shared equipment with an antiseptic wipe, as well as after every use, is also good practice. Another one is making every attempt to wash both hands with an anti-bacterial soap after removing protective gloves each time. All of these are good simple practices that will help lower the risk of infectious transmission after an exposure.

 

Despite the best precautions, bodily fluid exposure will occur at some point during a career in law enforcement. Not all bodily fluids have the same risk of infectious transmission.^5,6 The types of bodily fluid vary in risk of infectious transmission. Blood, semen and vaginal fluid exposure carry the highest risk of infection.^5,6 For HIV and Hepatitis B, there are currently no documented cases of transmission through urine, feces, sputum or vomitus.^5,6 In the dynamic world of law enforcement, determining what specific bodily fluid was included in an exposure is almost impossible. For a peace officer, all bodily fluid contacts should be treated the same. Post exposure, wash the affected area with an antiseptic soap as soon as time allows and scrub it vigorously. Contact a supervisor and inform them of the exposure. OSHA regulations require every department to have a formal bodily fluid exposure policy and plan.^7,8 Federal law requires that an employee be seen by a licensed physician within one hour of exposure.^7,8 Department supervisors should be able to provide guidance in regard to departmental policy and adherence to OSHA guidelines. Do not be embarrassed or reluctant to seek medical attention immediately. Federal law requires that all law enforcement agencies keep this information strictly confidential.^7,8 Do not deny the significance of a scratch or needle stick. Receiving care in hours — not days — can make the difference in life or death. Not all medical providers will be up to date on current CDC recommendations. Demand current CDC protocols be reviewed by your medical provider and presented to you with the facts of your case in mind. 

 

It is important to consider both the bodily fluid and the type of exposure. Not all exposures carry the same risk of infectious transmission. The CDC classifies exposure into three categories: Category I include all dirty needle sticks and contact of bodily fluids in the area of an open cut or wound.^5,6 For example, a human bite falls into Category I.^5,6 Category II includes exposure in the eyes, nose and mouth.^5,6 Category III includes contact with a bodily fluid on skin that has no open wounds or scratches.^5,6 The chance of infection after a category III exposure is virtually zero.^4,5

 

HIV is responsible for the AIDS syndrome. Though current treatment has made dramatic changes in how HIV is viewed, it has no cure or vaccine, and without treatment it will lead to death. Current data shows a transmission rate after an infected needle stick to be 0.3% and exposure with infected fluid with a wound or scrape on your skin to be 0.1%.^5,6 There are no current documented cases of transmission of HIV after exposure to infected fluid with intact skin, i.e., blood on hands, skin or uniform with no scrapes or cuts. The virus is considered to be very weak. It is typically killed with hand soap, clothing detergent or any of the commercial antiseptic lotions available.⁹ The virus dies very quickly when outside the body.⁹ If a category I or II exposure does occur, seek immediate medical attention. Do not wait to complete an assignment or shift.

 

In 2008, with never-reported details, previously sealed New York state court documents disclosed the medical retirements of four New York City police officers who were infected with HIV on the job. Court documents indicated one officer was cut with a contaminated razor blade, another one was bitten in the hand by a HIV positive criminal and the third sustained a cut to the hand while searching a prisoner.¹⁰ The route of infection for the fourth officer is not known. None of the infected officers completed exposure reports at the time of the incidents, making it impossible to prove their exposures were work related.⁹ At the time of the court hearings, one HIV infected female officer was also claiming duty-related exposure from her sexual relationship with one of the four infected male officers.^10,11,12 Brooklyn federal court records indicate that the NYPD Pension Board reviewed the claims of a total of 12 HIV infected officers from November 1999 and August 2007.¹⁰

 

The present antiviral drugs have been shown to be very successful in preventing viral transmission but must be started immediately if the exposure was high risk. Because not all people will tell you they are either HIV or Hepatitis positive or even know their status, knowing state law in regard to forced testing is important. The Fourth Amendment has jurisdiction over forced testing. Voluntary consent to test an individual’s blood is the best method to achieve results. While still in the field, try to get as much information about the person’s medical past. A history of IV drug use, incarcerations, sexual orientation and previous blood transfusions are important pieces of information in determining relative risk. While on scene, don’t be concerned about saving the needle or fluid-contaminated object involved in the exposure. Testing the fluid on the needle has shown to be very inaccurate and not worthwhile.⁶ Further, trying to transport the needle only increases the risk of being injured again. The information gathered from a suspect or victim will be very helpful to physicians when it is not clear cut if antiviral drugs will be recommended. The drugs have very serious side effects that need to be discussed prior to initiation of treatment. Because of this risk of these drugs, it is recommended that only certain exposures be treated.^5,6 If your exposure is not category I or II, no treatment is recommended.^5,6 If your exposure is a category I or II and the HIV status is not immediately known, your physician will discuss with you the options and risks. This is where finding out information on the subject or victim is so important. Female officers who could possibly be pregnant should have an immediate pregnancy test prior to starting any treatment.

 

Hepatitis B is one of the scariest of the “silent killers” out there. It can remain alive and infectious seven days outside the body.⁶ Like with HIV, there appears to be no known risk of transmission when Hepatitis B-infected blood makes contact with clothes or skin that has no wounds or scrapes.^5,6 Unlike HIV, the risk of transmission of Hepatitis B after a human bite is real.² Depending on the viral count in the infected blood, the chance of becoming infected can reach as high as 30% after a bite.² On July 24, 1991, Front Royal Police Lieutenant William Farrell died from complications of Hepatitis B. He contracted the virus during an on-duty fight where he was scratched and bitten.¹³ The Hepatitis B vaccine, a three-shot series, is very effective in prevention of this virus, but must be received prior to exposure. Becoming Hepatitis B positive will eventually lead to liver failure and death. After infection, there is no treatment at this time. By law, the Hepatitis B vaccine must be provided free of charge by your agency.^7,8 To be effective, the vaccination series should occur at the start of a career. Every 5-7 years, the effectiveness of the vaccine should be checked with a simple blood test. If you have had the vaccine and testing shows that it’s effective, there is no recommended treatment for a Hepatitis B exposure, regardless if the status of the subject is positive or not.⁶

 

Hepatitis C, like Hepatitis B infections, will ultimately lead to liver failure and death if a liver transplant is not available. The risk of infection after a dirty needle exposure is 1.8%.³ Risk after fluid exposure to your eyes or mouth is 0.9%.³ Though the risk of acquiring Hepatitis C from a human bite is much lower than Hepatitis B, the risk is estimated to be approximately 2% depending on the viral count of the infected person.¹⁴ There is no treatment currently for exposure to Hepatitis C infected fluid.⁵ During the ensuing fight and arrest of a drunk man 24 years ago, a Blue Mound Police Officer was bitten in the arm. After two years of unexplained fatigue, the officer was diagnosed with Hepatitis C. In 2010, the retired 57-year-old man was fighting liver cancer and cirrhosis and desperately waiting for a liver transplant to save his life.¹⁵ Unlike Hepatitis B, there is no vaccine to prevent the infection.⁵ It too can live outside the body for a long period of time, living up to four days at room temperature.^4,5 It is a very strong virus that is hard to kill and washing your hands may not be enough. Some recommend washing your exposed skin with diluted bleach, but this may not be practical. Because both forms of Hepatitis can survive outside the body for so long, cleaning all shared and restraint equipment is important.

 

How long these silent killers can live outside the body is important information to know and consider when thinking about possible treatments.

 

 

HIV    

Considered a very weak virus.

Usually killed with hand soap.

Dies very quickly outside the body.

 

HEPATITIS B           

One of the scariest of the silent killers.

Washing hands helps decrease risk of infection.

Can remain alive up to seven days outside the body.

 

HEPATITIS C           

Very strong virus that is hard to kill.

Washing hands may not be enough.

Can live up to four days outside the body.

 

Like all aspects in law enforcement, planning ahead and developing a routine is key to decreasing the risk of infectious fluid exposure. Wearing of gloves and eye protection should be part of every pre-shift checklist. Checking for any skin wounds and covering them with a waterproof barrier should occur before a uniform goes on. Spending a few moments cleaning the shared equipment should occur daily. Washing the area vigorously with anti-bacterial soap or the equivalent as soon as possible after exposure could be a life saving practice. Remembering to interview your subject or victim in regard to high-risk behavior will greatly help in defining the risk of an exposure and in evaluating treatment options. Their cooperation and voluntary consent will go a long way in expediting your need for immediate care and treatment. Don’t deny the danger of a silent killer.