The Scope of Hepatitis C

Hepatitis C (“HCV”) is a chronic viral blood-borne infect ion that infects between 4 and 5 million Americans (about 1 .8 percent of the population). It is a disease that was virtually unknown before the virus was isolated in 1989, and truly effective screening tests became available in 1992. Since then, it has emerged as a major public health concern.

Hepatitis C is often a hidden disease — after infection, it may develop over 10 to 30 years, usually without symptoms, until it surfaces as chronic active hepatitis. Only 5 percent of those currently infected with HCV are aware that they have the disease, and fewer than 2 percent have ever been treated.

Transmission of hepatitis C generally occurs through blood-to-blood contact. Most people currently carrying the disease, however, were infected sometime within the last thirty years, when blood transfusions and blood products were a significant source of infection. Prior to 1992, hepatitis C was prevalent in the nation’s blood supply.

The Impact of Hepatitis C on America’s Veterans

Veterans appear to have unusually high rates of hepatitis C. While the prevalence of hepatitis C in the population as a whole is 1.8%, various special studies of veterans in VA facilities have shown rates of hepatitis C infection between 10 and 20 percent.’

Hepatitis has historically been a disease associated with military service. Military training and combat offer many opportunities for transmission of blood-borne viral hepatitis through blood-to-blood contact. Field bleeding, surgery and transfusions, and exposure to blood by military medics and surgeons all constitute high risks.

Veterans of foreign combat are most at risk, where prevalence of hepatitis C is particularly high. All major engagements of the last 50 years — World War II, Korea, and Vietnam — had high rates of hepatitis. Viral hepatitis was viewed as a single disease in those years, and most treatment and documentation of it was for acute forms of the disease.

There are 3.2 million surviving Vietnam veterans who were in Asia during Vietnam Conflict. A conservative estimate is that 10 percent--320,000--of these veterans are now infected with HCV.

There are a number of likely risk factors related to the transmission of hepatitis C during the Vietnam War:

Asian Theater: Southeast Asia has high rates of hepatitis C infection. Currently, between 5 and 8 percent of the Vietnam population is infected with hepatitis C.2 Hepatitis C could have been transmitted to military personnel through tattoos, medical contact, sexual contact, and shared needles.

Transfusions: Three-hundred thousand Americans were wounded and 153,329 were hospitalized during the Vietnam War. Between March 1967 and June 1969, 364,900 transfusions were given in Vietnam.3 It is estimated that a minimum of 10 percent of those who were transfused received infected blood.4

Medical Contact: Surgeons, nurses, medics, helicopter crews, and others involved in evacuation and treatment of the wounded all were at risk for transmission of hepatitis C. An estimated 41.1 percent of all soldiers deployed to Vietnam — approximately 2.1 million — were exposed to combat. Many soldiers assisted the more than 300,000 wounded. In addition, many medical personnel, not exposed to combat because of their assignment to hospital ships, also handled wounded soldiers in the Vietnam theatre.5

Tattoos: Unclean needles that pierce the skin can transmit hepatitis C. While transmission of hepatitis C through tattoos has not been documented in the U.S., it has been documented elsewhere.6 An estimated 34 percent of active duty military personnel have tattoos.7 Many of these are acquired in regions where sanitation is not optimal.

Sexual Contact: Although sexual transmission of hepatitis C is possible, it is believed to be relatively uncommon. Nevertheless, a portion of the HCV transmission during the Vietnam War could have come through sexual involvement with Vietnamese nationals.

Drug Use: Sharing drug paraphernalia is the most common cause of HCV transmission for new cases acquired today. it was also a factor in HCV transmission in Vietnam. A CDC study of the health status of Vietnam veterans found that 3% had used “hard drugs” defined to include amphetamines, barbiturates, cocaine, heroin, psychedelics, phencyclidine and methaqualone.8

The VA’s Monitoring of HCV-Infected Veterans

The Department of Veterans Affairs (VA) has been monitoring HCV cases and has noted a decided increase in the number of cases over the last few years. There were 6,600 HCV cases reported in the VA in 1991. By 1994, this number had increased to 18,854.~ Between 1995 and 1997 the annual number of newly identified persons rose from 20,203 to 21,424 to 24,850. In 1998 an additional 29,799 unique cases were recorded within the VA. VA officials expect this number to continue to rise substantially. Of all veterans in the VA system testing positive for hepatitis C, 64% were Vietnam Era veterans. The mean age of HCV­infected veterans is 49 years.10

Testing of veterans outside the VA medical system has further confirmed high HCV infection rates. A blood screening of 200 apparently healthy leaders of the Vietnam Veterans of America conducted in July 1998 revealed that 9 percent were infected with hepatitis C virus.11 A recent screening at a Vietnam Veterans’ standdown revealed that 36% were infected with HCV.12 Although all of these numbers are preliminary, they reveal consistently high rates of HCV infection that range at or above 10 percent — more than 5 times the rate in the general population.

In June 1998 VA issued new guidelines for screening veterans entering VA facilities who are considered to have one of ten specified hepatitis C risk factors. The VA expects that screening will dramatically increase the number of VA patients identified with hepatitis C and the demand for VA services to treat liver disease. The screening guidelines indicate that any veteran who requests HCV testing should be tested regardless of risk. In December of last year VA adopted treatment guidelines for HCV infection. The guidelines recommend that eligible veterans be given the very best in medical care including the most recently approved treatment. Of course, only veterans who are income eligible or service connected for HCV can receive treatment through a VA Medical Center. However, veterans report problems with obtaining this care due to constraints put on hepatitis C care at the VISN level.

Treatment Is Unlikely Without Service Connection

The VA Medical Center (‘VAMC”) system has been reorganized and has placed all veterans into one of seven categories, according to a veteran’s medical priority. Currently, all veterans, regardless of their category, receive medical treatment when they come to a VAMC; however, due to budget constraints in FY2000, it is expected that any veteran who falls into category seven (“nonservice-connected veterans and noncompensable zero percent service-connected veterans who agree to pay copayments”) will be denied medical treatment at a VAMC. Thus, it is critically important for veterans with hepatitis C to be granted presumptive service-connection for their disease. Otherwise, untreated HCV can develop into life-threatening advanced liver disease.

Veterans infected with hepatitis C during their military service are generally unable to establish a service connection. The lack of knowledge of hepatitis C and, until recently, the lack of a reliable test, not to mention the long latency period of this disease all make it difficult to prove that the infection was acquired

during military service. Without a presumption of service connection, most veterans will be unable to meet the standard of proof necessary to show that they contracted HCV during their military service. As the VA’s budget continues to shrink, veterans without a service-connected injury — including veterans with HCV -- will be turned away from VAMC’s.

Vietnam veterans are the group most directly affected by this problem today. Many veterans who contracted hepatitis C in Vietnam 25 to 30 years ago would only now be exhibiting symptoms of severe liver disease. When they were first infected, HCV had not been distinguished from other forms of hepatitis. In 85 percent of the cases, there would have been no acute symptoms at the time of infection.

Detecting hepatitis C infection at the time of discharge was also impossible. Many of today’s HCV-infected veterans were discharged from the military before tests for hepatitis C existed. Even today, when there are reliable tests for hepatitis C, the military does not conduct HCV tests as part of the discharge physical.

HCV-infected veterans who were treated for acute hepatitis during their military service and who now appear before the Board of Veterans’ Appeals (“BVA”) to establish service connection are most often denied because they cannot prove that the current hepatitis C infection is related to the prior hepatitis attack. The Board often rejects a claim for service-connection because the veteran’s medical record does not show presence of HCV at the time of discharge. In fact, in a review of all 1599 cases of chronic hepatitis brought before BVA between 1994 and 1996, only 37 resulted in approval of a service-related disability rating for hepatitis.13

Presumptive service-connection will enable veterans to get tested for hepatitis C and treated, if appropriate, through the VA. It will also enable veterans who progress to severe liver disease to get adequate treatment through the VA.

1 Veterans Health Administration. Under Secretary for Health’s Information Letter. “Hepatitis C: Standards for Provider Evaluation and Testing.” IL 10-98-01 3, June 11,1998.

2 Markers of hepatitis C and R virus infections among blood donors in Ho Chi Minh City and Hanoi, Vietnam. CIin Diagn Lab lmmunol. 1994:1(4): 413-8.

~ “Information Concerning Vietnam.” Armed Services Blood Program Office. Office of Health Affairs, Department of Defense. July 24, 1998.

~ HJ Alter, et al. A controlled prospective study of transfusion-associated hepatitis. Intramural

Research Project 201 CL-02005-28 DTM.

~ National Survey of Veterans (NSV9503) National Center for Veteran Analysis and Statistics.

Office of the Assistant Secretary for Policy and Planning. Department of Veteran Affairs. April

1995. p.28.

6 P. Pawli, GJ Bayless, OF Dent, MR Sunzer. The prevalence of serological markers for hepatitis

B virus infection in Australian naval personnel. Medical Journal of Australia 1989:151(2): 71-75.

~ Personal Communication with Capt. John Mateczun, Principal Director, Clinical Affairs, Office of

Health Affairs, Department of Defense. March 17, 1997.

“Health Status of Vietnam Veterans.” Volume 1, Synopsis. The Centers for Disease Control. Vietnam Experience Study. US Department of Health and Human Services, Public Health Service. January 1989.

Roselle GA, Mendenhall CL, Danko LH. “A four-year review of patients with hepatitis C antibody in Department of Veterans Affairs facilities.” Military Medicine. 1997;1 1:711-714.

10 Presentation of Gay Roselle to the Veterans of Foreign Wars. April 9, 1999. Washington, DC. ~ Spolarich AW, Russo B. “Hepatitis C infection in apparently healthy Vietnam Era veterans.” Submitted for publication. November 1998.

12 Personal communication with Marsha L. Four, Executive Director, Philadelphia Standdown, Philadelphia, PA. October 1998.

13 “Board of Veterans’ Appeals 1994-1 996 Decisions.” Published on CD-ROM by the Department  of Veterans Affairs. 1998.