Citation Nr: 1512625	
Decision Date: 03/25/15    Archive Date: 04/01/15

DOCKET NO.  13-06 352A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUE

Entitlement to service connection for hepatitis C.


REPRESENTATION

Appellant represented by:	Peter J. Meadows, Attorney


ATTORNEY FOR THE BOARD

T. J. Anthony, Associate Counsel


INTRODUCTION

The Veteran had active service from February 1972 to February 1975.

This matter is before the Board of Veterans' Appeals (Board) on appeal of a September 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.


FINDING OF FACT

The most probative evidence of record does not show that it is at least as likely as not that the Veteran's hepatitis C is etiologically related to his active service.


CONCLUSION OF LAW

The criteria for service connection for hepatitis C have not been met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303 (2014).


REASONS AND BASES FOR FINDING AND CONCLUSION

VA's Duty to Notify and Assist

Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

A VA letter issued in April 2010 satisfied the duty to notify provisions with respect to service connection.  The letter notified the Veteran of the factors pertinent to the establishment of an effective date and disability rating in the event of a grant of service connection for hepatitis C.

VA has also satisfied its duty to assist the Veteran.  The service treatment records, VA treatment records, and private treatment records have been associated with the claims file.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.  The Veteran was provided a VA examination in September 2010 in relation to his hepatitis C.  To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate for decision making.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  Here, the examiner reviewed the claims file, considered the Veteran's reported symptomatology, and addressed the likely etiology of the Veteran's hepatitis C, providing supporting explanation and rationale for all conclusions reached.  The examination was thorough and all necessary evidence and testing was considered by the examiner.  Therefore, the Board finds the examination to be adequate.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board notes that the record reflects that the Veteran is in receipt of Social Security Administration disability benefits.  However, there is no indication that these benefits are relevant to the issue on appeal.  Specifically, there is no indication that records associated with the benefits are pertinent to establishing the etiology of the Veteran's hepatitis C.  The Veteran has not identified these records as relevant to the issue on appeal, and a remand for these records is therefore not required.  See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). 

There is no indication in the record that any additional evidence, relevant to the issue adjudicated in this decision, is available and not part of the claims file.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless.  See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009).

Legal Criteria

Generally, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2014).  To establish service connection for a disability, the Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred in or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Analysis

Risk factors for hepatitis C include intravenous drug use, blood transfusions before 1992, hemodialysis, intranasal drug use, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, and shared toothbrushes or razor blades.  See VBA letter 211B (98-110) Nov. 30, 1998. 

According to VA Fast Letter 04-13 (June 29, 2004), hepatitis C is spread primarily by contact with blood and blood products.  The highest prevalence of hepatitis C infection is among those with repeated, direct percutaneous (through the skin) exposures to blood (e.g., injection drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and people with hemophilia who were treated with clotting factor concentrates before 1987).  The Fast Letter further states that, although transmission through air gun injection is biologically plausible, there have been no case reports of hepatitis C being transmitted by such means.  The Fast Letter concludes that it is essential that the examination report upon which the determination of service connection is made include a full discussion of all modes of transmission, and a rationale as to why the examiner believes the particular mode of transmission was the source of a veteran's hepatitis C.

The Veteran contends that his current hepatitis C is etiologically related to his active service.  In his claim, the Veteran indicated that he believes his hepatitis C is the result of receiving injections via air gun injector during service.  See VA Form 21-526, Veteran's Application for Compensation and/or Pension, received March 2010.

The Veteran's service treatment records show that a medical report of examination upon entrance, dated September 1971, documented normal systems except for body marks and a nonunion fracture of the foot.  Medical records dated May 29, 1973, note rule-out diagnoses for hepatitis and "mono."  Medical records dated May 31, 1973, note a diagnosis of "resolving hepatitis."  On a medical history report dated October 1974, the Veteran denied any history of hepatitis.  A medical report of examination upon discharge, dated January 1975, documented normal systems and made no note of hepatitis or any other liver disease.  The service treatment records do not specifically document any instances in which the Veteran received injections via air gun injector.  However, such injections were administered during the Veteran's period of active service, and there is nothing in the record that calls into question the Veteran's credibility with regard to his reports of receiving such injections.  Accordingly, the Board resolves any doubt in the Veteran's favor, and finds that the Veteran did in fact receive injections via air injector during active service.

VA treatment records document that the Veteran's reported that he was diagnosed with hepatitis C in August 2001.  The most recent treatment notes of record indicate that the Veteran continues to have a diagnosis for hepatitis C.  The Veteran reported to the September 2010 VA examiner that he received tattoos around 1998, and again around 1999.

Upon examining the Veteran and reviewing the claims file, the September 2010 VA examiner opined that she could not offer an opinion as to any relationship between the Veteran's current hepatitis C and his active service because "such knowledge is not available in the medical literature, and any opinion would be speculation."  The examiner further explained that she was "unable to say for certain" that there is a causal link between the Veteran's service and the current hepatitis C as the Veteran had tattoos around 1998 and 1999, and that the tattoos "may have been the source of infection."  The examiner also noted that the Veteran's in-service hepatitis was not chronic.  Rather, it appears to have resolved as it was not noted on the separation examination in 1975, and there is no evidence of any liver disease between 1973 and 2001.  The examiner concluded that she could not say that the Veteran's air gun injections caused his hepatitis C without speculation.

In November 2010, the Veteran submitted a private medical opinion from B. S. Sreenath, M.D.  Dr. Sreenath indicates he has treated the Veteran's hepatitis C and related symptoms, and opines that the Veteran's hepatitis C "was probably from air guns that were being used for vaccination purposes in 1972/1973 when he was in the military."  Dr. Sreenath notes that the Veteran received his tattoos "much later" in 1998.  Dr. Sreenath further states that the hepatitis the Veteran was diagnosed with in service "was probably labeled as Non A/Non B" and that the majority of Non A/Non B hepatitis cases were related to hepatitis C.

In November 2013, the Veteran submitted an opinion from C. L. Koah stating that it is at least as likely as not that the Veteran's hepatitis C had its origin in and is related to his military service.  As rationale, Mr. Koah notes that Veteran was diagnosed with some form of hepatitis in service, and that "a review of VA results with other veterans applying for disability for hepatitis indicates that it is 'biologically plausible' that hepatitis C could result from air gun transmissions."

Accordingly, the record shows that the Veteran has a current disability of hepatitis C, that he was diagnosed with some form of hepatitis during active service, and that he received injections via air injector gun during active service.  Thus, there is evidence of a current disability and an in-service event, injury, or disease, and the issue remaining for discussion is whether there is a medical nexus between the in-service event, injury, or disease and the current diagnosis of hepatitis C.

To determine whether there is such a medical nexus, the Board turns to the competent evidence of record.  Initially, the Board acknowledges the Veteran's assertions that his current hepatitis C is the result of in-service injections administered via air injector gun.  Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation.  38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006).  Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person.  See Jandreau, 492 F.3d 1372.  In this case, the etiology of hepatitis C is a complex medical question that falls outside the realm of common knowledge of a lay person as it requires medical knowledge and expertise.  The Veteran has not been shown to possess such medical knowledge and expertise.  As such, the Veteran's statements are not considered competent evidence on the matter, and are therefore not for consideration in determining the etiology of the hepatitis C.

The Board also acknowledges the November 2013 positive nexus opinion from C. L. Koah.  Mr. Koah lists his credentials as diplomate - American Board of Disability Analysts, licensed professional counselor, certified rehabilitation counselor, certified vocational evaluator, contract counselor - VAMC Virginia Vet Centers, and Department of Veterans Affairs evaluator.  None of these credentials indicate that Mr. Koah has received the sort of medical training that would provide the medical knowledge and expertise necessary to render a competent opinion on a complex medical question such as the etiology of hepatitis C.  Therefore, for the same reasons the Veteran's lay statements are not considered competent evidence, Mr. Koah's nexus opinion is also not considered competent evidence on the matter, and is therefore not for consideration in determining the etiology of the Veteran's hepatitis C.  See Jandreau, 492 F.3d 1372.

There are two competent medical opinions of record: the negative nexus opinion provided by the September 2010 VA examiner, and the positive nexus opinion provided by Dr. Sreenath.  The United States Court of Appeals for Veterans Claims has stated that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.  Further, the credibility and weight to be attached to these opinions are within the province of the adjudicator.  See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).  As such, the Board may appropriately favor the opinion of one competent medical authority over another.  See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001).

The Board concludes that the weight of the competent evidence is against the Veteran's claim.  In this regard, the Board affords greater probative weight to the September 2010 VA examiner's opinion for the reasons explained below.

First, Dr. Sreenath's suggestion that the in-service diagnosis is related to the Veteran's present hepatitis C is speculative and does not reflect full consideration of the medical records.  Specifically, Dr. Sreenath posits that the in-service hepatitis "was probably labeled as Non A/Non B" and that "the majority of Non A/Non B hepatitis were related to hepatitis C."  A review of the Veteran's records reveals that the diagnosis on May 29, 1973, was "r/o hepatitis," and the diagnosis on May 31, 1973, was "resolving hepatitis."  Thus, the record shows that the hepatitis was never labeled as Non A/Non B, and to say that it was probably labeled as such would be pure speculation.  Furthermore, as noted by the VA examiner, the record shows that on discharge in January 1975, the Veteran was not noted to have hepatitis, and there is no further evidence of hepatitis until 2001, over two decades after the Veteran's discharge from active service.  Accordingly, as noted by the VA examiner, it appears that the Veteran's in-service hepatitis was acute and resolved prior to his discharge from service.  Dr. Sreenath does not acknowledge this, and does not explain why it is more likely than not that the current hepatitis C is etiologically related to the in-service hepatitis in light of the absence of any showing of symptomatology or diagnosis of liver disease between 1973 and 2001.

Second, Dr. Sreenath does not explain why it is at least as likely as not that the Veteran's current hepatitis C is etiologically related to his in-service injections via air injector gun despite evidence of the post-service risk factor of tattoos received in 1998 and again in 1999.  Dr. Sreenath only states that the tattoos were received "much later" than the Veteran's active service in 1998.  Dr. Sreenath does not acknowledge that the Veteran was not formally diagnosed with hepatitis C until 2001, which is after he received the tattoos, and that the tattoos therefore might also have been the cause of the current hepatitis C.  Although VA has conceded that it is biologically possible for hepatitis C to be transmitted through air gun injections, VA also requires "a full discussion of all modes of transmission, and a rationale as to why the examiner believes the air gun was the source of the veteran's hepatitis C."  Fast Letter 211 (04-13), June 29, 2004.   Dr. Sreenath provided no such rationale, which limits the probative value of his opinion.

On the other hand, the September 2010 VA examiner reviewed the claims file, personally examined the Veteran, and considered the Veteran's reported symptomatology.  The VA examiner's opinion reflects full consideration of the Veteran's medical history, as documented in the medical record, and full consideration of all possible hepatitis C risk factors, to include the tattoos the Veteran received in 1998, and again in 1999.  Accordingly, the Board finds that the VA examiner's opinion that it would be speculative to medically attribute the Veteran's current hepatitis C to the in-service injections via air gun injection to be based on better knowledge of the record and better skill in analyzing the data.  As the opinion is better supported by the evidence of record than the positive nexus opinion from Dr. Sreenath, it is due greater probative weight.

The Board recognizes that when an examiner is asked to render an etiology opinion and determines that she cannot do so without resorting to speculation, the Board may not rely on such an opinion unless the record in its entirety, including the examination and the opinion itself, shows that "the examiner [did] not invoke the phrase 'without resort to mere speculation' as a substitute for the full consideration of all pertinent and available medical facts."  Jones v. Shinseki, 23 Vet. App. 382 (2010).  "[I]t must be clear on the record that the inability to opine on questions of diagnosis and etiology is not the first impression of an uninformed examiner, but rather an assessment arrived at after all due diligence in seeking relevant medical information that may have bearing on the requested opinion."  Id. At 389.

Here, the Board finds the VA examiner's resort to speculation justified.  Multiple hepatitis C risk factors appear in the record.  The examiner's rationale as to why she could only speculate was centered on the presence of both in-service and post-service hepatitis C risk factors.  The examiner detailed the Veteran's history of a hepatitis diagnosis and injections via air gun injector during service as well as the history of tattoos post service.  The examiner noted that the in-service diagnosis for hepatitis was not chronic and appears to have resolved prior to discharge with no further evidence of hepatitis for decades after service.  The examiner further noted that the Veteran received his tattoos after service but prior to being diagnosed with hepatitis C, and that "the tattoos may have been the source of infections."  Finally, the examiner notes that to attribute a hepatitis infection to air gun injections would be speculative because such is not supported by current medical literature.  Of note, this conclusion is consistent with VA Fast Letter 04-13, which states that infection by such means is biologically plausible, but that there have been no case reports of hepatitis C being transmitted by an air gun injection.  Thus, although the VA examiner concluded that speculation would be necessary to causally link the Veteran's hepatitis C to any particular risk fact, the examiner provided an appropriate and full rationale as to why a definitive opinion as to the etiology of the Veteran's hepatitis C could not be provided.  See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010).

In summary, the record reflects that the Veteran has both in-service and post-service risk factors for hepatitis C.  Although he was diagnosed with hepatitis during active service, the hepatitis was not chronic, and appears to have resolved prior to his discharge from active service.  He was not diagnosed with hepatitis C for many years after service.  The most probative evidence of record does not show that it is at least as likely as not that the Veteran's current hepatitis C is etiologically related to his active service.  Therefore, the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application, and the claim must be denied.  Gilbert v. Derwinski, 1 Vet. App. 4 (1990); 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2014).


ORDER

Entitlement to service connection for hepatitis C is denied.



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U. R. POWELL
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs