Hepatitis C In Veterans
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
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
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
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
Hepatitis C could have been transmitted to military personnel
through tattoos, medical contact, sexual contact, and shared
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
Many of these are acquired in regions where sanitation is not
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
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
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
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
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
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
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
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
~ 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
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.
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.