Citation Nr: 1303555 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 05-32 504A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for hepatitis C, to include under the provisions of 38 U.S.C.A. § 1151. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from May 1974 to June 1974 and from May 1975 to September 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal of a December 2004 and December 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied service connection for the above-referenced claim. The Veteran testified before the undersigned at a March 2009 Video Conference hearing held at the RO. The hearing transcript is of record. In a May 2009 decision, the Board denied service connection for hepatitis C, to include under the provision of 38 C.F.R. §38 U.S.C.A. § 1151. Thereafter, the Veteran appealed the Board's denial of his claim to the United States Court of Appeals for Veterans Claims (Court). In March 2010, the Veteran and the Secretary of the VA (the parties) filed a Joint Motion for Partial Remand (Joint Motion) with respect to the claim of entitlement to service connection for hepatitis C. (As is noted in footnote 1 of the Joint Motion, the portion of the Board's May 2009 decision to reopen the hepatitis C claim is left undisturbed). The Joint Motion moved for the Court to vacate and remand the May 2009 Board decision, as the parties determined that a remand was necessary so that the Board could determine whether the duty to assist had been satisfied and provide further explanation of the reasons and bases for its decision. In March 2010, the Court granted the parties' Joint Motion. In August 2010, the Board remanded the case for further development by the originating agency. The case was then returned to the Board for further appellate action in May 2012. At that time, the Board requested an expert opinion via the Veteran's Health Administration (VHA). An opinion was provided in November 2012 and has been associated with the record. FINDINGS OF FACT 1. The evidence of record does not show that the Veteran's hepatitis C disorder is etiologically related to his military service. 2. The evidence of record does not show that the Veteran's hepatitis C disorder resulted from or was aggravated by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical or surgical care in connection with a November 1994 lung surgery. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C have not been met. 38 U.S.C.A. §§ 1110, 1131, 1112, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304, 3.307. 3.309 (2012). 2. The criteria for compensation under the provision of 38 U.S.C.A. § 1151 for hepatitis C due to VA treatment have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In November 2004 and September 2005 letters, the RO notified the Veteran of the evidence needed to substantiate his claim for service connection. The letter satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Veteran has substantiated his status as a Veteran and the second and third elements of Dingess notice are satisfied by the November 2004 and September 2005 letters. However, the Veteran did not receive notice about the evidence needed to establish a disability rating or notice regarding an effective date. Since the claim is being denied, no rating is being given and no effective date is being set. The failure to provide notice on the effective date and rating elements of the claim is harmless. Smith v. Shinseki, No. 08-1667 (Aug. 17, 2010). The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4). All service treatment records and pertinent VA medical records have been obtained. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See Green v. Derwinski, 1 Vet. App. 121 (1991). The Veteran was afforded VA examinations in November 2005, October 2010, with an addendum submitted in December 2011, and August 2011. Furthermore, as directed by the Board in May 2012, a November 2012 opinion was obtained from the VHA, so as to ascertain whether the Veteran's hepatitis C is etiologically related to his active military service. To that end, when VA obtains a medical opinion, it must ensure that the opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA opinions of November 2005, August 2011 and December 2011, as well as the VHA opinion of November 2012, are adequate, as the examiners included a thorough review of the file and provided findings relevant to the issues at hand. The Veteran's complaints and lay history were also considered and discussed, and a rationale was provided. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA opinion with respect to these issues on appeal has been met. See 38 C.F.R. § 3.159(c)(4) (2012). The Board finds that VA has complied with the VCAA's notification and assistance requirements and the appeal is ready to be considered on the merits. Factual Background The Veteran contends that his currently diagnosed hepatitis C developed as a result of his active military service. Specifically, he contends that he contracted hepatitis C from in-service inoculations he received through the use of an injection gun; thus, he claims that he should be awarded service connection on a direct basis. Alternatively, he argues that he may have contracted the virus as a result of improper medical care he received at a VA medical facility (VAMC) during lung surgery in November 1994. Specifically, he argues that he may have been exposed through blood transfusions he claims he received during the lung procedure, from VA medical personnel not wearing gloves during the procedure, and as a result of a VA medical professional improperly inserting a chest tube prior to his surgery. Service treatment records are negative for symptoms or diagnosis relevant to hepatitis C. These records show that he received immunizations while on active duty. However, there is no clear indication from these records whether injection guns were used to administer his inoculations. VA outpatient treatment records show that the Veteran underwent treatment for unrelated disorders in the decades immediately following his separation. These records reveal that he was treated in 1991 for alcoholism. Significantly, the records show that the Veteran underwent diagnostic testing in September 1993, which was negative for hepatitis C. Additional VA treatment records reveal that the Veteran underwent lung surgery at a VA medical facility in November 1994 to treat a right lung pnuemothorax. Prior to the surgery, a right chest tube was inserted, which was noted to be kinked on a November 1994 chest X-ray; there is no indication from these records that the Veteran experienced any complications due to the kinked right chest tube. The Veteran subsequently underwent a right posterolateral thoracotomy and decortications in November 1994, for which consent was completed. The associated operative report reveals that the Veteran tolerated the procedure well; his estimated blood loss was 150 cc. An associated anesthesia report reveals an estimated blood loss of 300 cc. The associated surgery report reveals that 24 units of blood were available during the surgery, but there is no indication that the Veteran received a blood transfusion in connection with the surgery. Instead, the operative report reveals that he was given over two litters of intravenous (IV) fluids. A December 1994 discharge summary report indicates that the Veteran received in-patient treatment for approximately two weeks following his surgery and that he did very well. Overall, there is no indication from these records that the Veteran received a blood transfusion in connection with his November 1994 surgery, or that the treatment provided was improperly performed. Subsequent VA medical records show that the Veteran received in-patient treatment for unrelated conditions in December 1996. He was noted to have undergone lung surgery and the examiner noted that the Veteran was hepatitis C positive prior to his surgery. The Veteran reported a history of binge drinking. Diagnostic testing was performed in December 1996 to confirm this diagnosis, which revealed that the Veteran was positive for hepatitis C. Subsequent VA treatment records document the Veteran's treatment for unrelated conditions. Of particular note is a September 2000 VA treatment record showing that the Veteran requested testing for a sexually transmitted disease; on the associated risk factors questionnaire, he reported that he had a history of unprotected sex and a blood transfusion in 1994. A January 2002 VA treatment record documents the Veteran's report of trying to remain sober. The Veteran's claim file was reviewed by a VA examiner in November 2005 for the purpose of obtaining a medical opinion with respect to his § 1151 claim. The examiner noted her review of the medical records associated with the Veteran's November 1994 lung surgery. She highlighted that the intraoperative note and the anesthesia report associated with the surgery did not show that the Veteran received any blood transfusions. The examiner also noted a February 2001 VA medical record, in which it was noted that the Veteran had been recently diagnosed with hepatitis C. She concluded that with no evidence to support a blood transfusion during the November 1994 surgery, there was no medical basis to link his surgery to his development of hepatitis C. Thus, the examiner opined that the Veteran's hepatitis C was not caused by or the result of his lung surgery in 1994 at a VA medical facility. In support of his service connection claim, the Veteran submitted an April 2010 letter from the Military Vaccine Agency of the Department of the Army Office of the Surgeon General. In the letter, the Director of the Agency noted the Veteran's military service from 1974 to 1976. He stated that it was highly probable that the Veteran received jet injector immunizations during his military service, "as it was common practice for service members to receive immunizations in this manner at most Army basic training sites during the 1970s." In October 2010, the Veteran underwent a VA examination in connection with his claim for direct service connection. The VA examiner indicated that he reviewed the Veteran's claims file in conjunction with the examination. The Veteran reported that he was told that he had hepatitis C in 1994 after he underwent lung surgery. He asserted that he probably contracted the virus in 1974 when he was inoculated by the use of an air gun during his military service. The examiner acknowledged the April 2010 letter from the Military Vaccine Agency regarding the Veteran's probable immunizations via jet injectors. He further noted that the medical records associated with the Veteran's lung surgery did not indicate any significant blood loss or transfusion of blood products. According to the examiner's review of the claims file, the Veteran's hepatitis profile dating back to 1988 showed elevated liver function tests (LTFs). He highlighted that the Veteran's hepatitis C test was negative 1993 but was positive in 1996. The Veteran underwent a clinical examination, which confirmed the diagnosis of chronic hepatitis C. Following the examination, the examiner identified the risk factor that was most likely the cause of the Veteran's hepatitis C as precutaneous exposure to blood by jet-injector immunizations in service. The examiner opined that it was at least as likely as not that the Veteran contracted hepatitis C during his military service. In August 2011, the Veteran underwent a second VA examination to assess the etiology of his claimed hepatitis C disorder. The claims file was reviewed by the VA examiner in conjunction with the examination. The examiner noted the Veteran's claim that he contracted hepatitis C from inoculations shot via the use of a jet injector gun and the Veteran's report of "feeling bad" directly after the incident. The Veteran reported that his eyes turned yellow approximately one week following his discharge from the military and again following his lung surgery. He stated that he was diagnosed with hepatitis C in 1993 following his lung surgery. Following the examination, the Veteran's was again diagnosed with hepatitis C. The examiner concluded that hepatitis C was not corroborated as having occurred during the Veteran's military service. In rendering her opinion, she noted that the Veteran was not treated for this condition and did not complain of abdominal pain while in the military. She noted further that there was no evidence that service members had acquired blood borne infections, such as hepatitis C, as the result of the military's use of jet injectors. However, she also noted that concerns about the safety of jet injections prompted the discontinued routine use of jet injectors in the military. The examiner noted a 1988 letter from a Department of Defense health official knowledgeable in the field to Congress, in which the physician stated that the use of jet injectors in the military had never been implicated in the transmission of blood borne infections. According to the letter, the Centers for Disease Control and Prevention and the World Health Organization indicated that, worldwide, jet injectors were generally considered safe and effective for delivering vaccines if used properly. It was also reported in the letter essentially that the military discontinued the use of the injectors in 1997 essentially due to the manufacturer's decision to discontinue producing and servicing the devices. Thereafter, the RO requested an addendum opinion from the VA examiner who performed the October 2010 examiner and requested that the examiner provide a basis to support his opinion in support of the Veteran's claim. Specifically, the RO requested that the examiner address all possible modes of transmission of hepatitis C as related to the Veteran's case and a detailed rationale to support the opinion provided in the October 2010 examination report. In a December 2011 addendum report, the examiner indicated that he again reviewed the Veteran's claims file. He also noted his review of VA Fast Letter 04-13 (June 29, 2004). After his review, the examiner amended his previous opinion regarding the etiology of the Veteran's hepatitis C. He explained that after thorough reinvestigation and review of the Veteran's case, it was less likely than not that the Veteran's hepatitis C was incurred in or caused by jet injector immunizations during his military service, given the lack of corroborative evidence for the transmission of hepatitis C by air gun injectors. The examiner discussed the other possible risk factors for transmission of hepatitis C, and noted that the Veteran denied a history of injection drug use and his medical history negative for a history of a blood transfusion or contamination with blood products. He acknowledges that the Veteran had several tattoos during his military service and that he had a history of unprotected sex with multiple partners. The examiner stated that the most convincing evidence to support the low likelihood that the Veteran contracted hepatitis C through the use of in-service injector immunizations was the negative hepatitis C test in 1993 and the subsequent positive test in 1996. According to the examiner, if the Veteran had contracted hepatitis C during the service via jet injector immunizations, his 1993 hepatitis C test should have been positive, as it was approximately twenty years after his discharge. As noted above, the Board requested a VHA opinion in May 2012. A VHA specialist submitted an opinion in November 2012. The specialist opined that it is not at least as likely as not that the Veteran's hepatitis C is related to immunizations he received via air injector guns during his military service. In rendering his opinion, the specialist noted that although the Veteran may have received jet injector immunizations during his military service from 1974 to 1976, his testing for hepatitis C was negative in September 1993, and as the antibody test for hepatitis C is very sensitive and is designed to pick up all patients who are infected with the virus, a false negative test at that time (1993) would be unlikely. The VHA specialist noted further that although the Veteran did have elevated liver function tests dating back to 1998, several other causes for these abnormal findings could exist, (i.e. alcohol use/abuse, fatty liver disease, medications) and therefore, the abnormal liver function tests cannot be directly attributed to hepatitis C in this case. The specialist noted further that although when questioned about his risk factors for contracting hepatitis C, the Veteran denied intravenous drug abuse, nasal cocaine use, or a history of blood transfusion; he did admit to other risk factors including, receiving tattoos and having unprotected sex with multiple partners. Finally, the specialist concluded that the negative hepatitis C test in 1993 is extremely important in this Veteran's case, as it suggests that the virus was contracted at some point between 1993 and 1996. He also noted that he agreed with the October 2010 VA examiner's second opinion. Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009). "[L]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Direct service connection may be granted only when a disability or cause of death was incurred or aggravated in line of duty, and not the result of the Veteran's own willful misconduct; or, for claims filed after October 31, 1990, not the result of abuse of alcohol or drugs. 38 C.F.R. § 3.301(a). An injury or disease incurred during active military, naval, or air service shall not be deemed to have been incurred in line of duty if such injury or disease was a result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. For the purpose of this paragraph, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C.A. § 105 (West 2002); 38 C.F.R. § 3.1(m). VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCPREC 7-99 (1999), published at 64 Fed. Reg. 52,375 (June 9, 1999); VAOPGCPREC 2-98 (1998), published at 63 Fed. Reg. 31,263 (February 10, 1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Several risk factors for hepatitis C have been recognized by VA. These include: transfusion of blood or blood product before 1992, organ transplant before 1992, hemodialysis, tattoos, body piercing, intravenous drug use (from shared instruments), high-risk sexual activity, intranasal cocaine (from shared instruments), accidental exposure to blood products as a health care worker, combat medic, or corpsman by percutaneous (through the skin) exposure or mucous membrane exposure, and other direct percutaneous exposure to blood such as by acupuncture with non-sterile needles or the sharing of toothbrushes or shaving razors. VA Training Letter 211A (01-02) (April 17, 2001); VA Fast Letter 211B (98-110) (November 30, 1998). The following key points regarding the contraction of hepatitis C also have been recognized. Hepatitis C is spread primarily by contact with blood and blood products. VA Fast Letter 04-13 (June 29, 2004). The highest prevalence of hepatitis C thus is among those with repeated, direct percutaneous exposure to blood (i.e., injection drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). Id. Since the 1990's injection drug use has been the principal mode of transmission, as better screening procedures effectively inactivate the virus in blood to be transfused. Id. Hepatitis C can be transmitted sexually, though the risk was less than 5 percent in one study. Id. Hepatitis C also can be transmitted through an accidental needle stick for those with health care occupations, and with the reuse of contaminated needles including for tattoos, body piercing, and acupuncture. Id. The source of infection is unknown in approximately 10 percent of acute and 30 percent of chronic hepatitis C cases. Id. They may have come from blood-contaminated cuts or wounds, contaminated medical equipment, or multi-dose vials of medications. Id. As such, VA has concluded that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992 and injection drug use. Id. Yet VA also has recognized that transmission of hepatitis C through jet injectors is "biologically plausible." Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380- 81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the instant claim. Analysis Based on the above, the Board finds that service connection for hepatitis C is not warranted. As previously determined, the requirements for presumptive service connection for a chronic disease have not been met. Neither have all of the requirements for direct service connection, whether generally, through continuity of symptomatology, or otherwise. With respect to direct service connection, it remains undisputed that the Veteran currently has hepatitis C. As discussed above, the Veteran was diagnosed with the claimed disorder in December 1996 after undergoing diagnostic testing. His diagnosis has been repetitively confirmed during subsequent VA examinations conducted in October 2010 and August 2011. The Veteran essentially relates his current hepatitis C diagnosis to an in-service occurrence. Specifically, he attributes his diagnosis to the in-service immunizations he received via the use of an air gun injector. The Veteran's service treatment records are negative for reports or treatment for any symptomatology related to the hepatitis C virus. However, the Veteran has reported "feeling bad" and experiencing yellowing of his eyes following his receipt of the air gun injector immunizations. Based on his account, the relevant inquiries are whether this in-service risk factor identified by the Veteran can be established and whether it is related to his currently diagnosed hepatitis C disorder. In this case, it is undisputed that the Veteran received several immunizations during service because they are documented in the service treatment records. The Veteran is competent to state that air injector guns were the method of delivery of these immunizations because such events are within his personal experience. See Layno v. Brown, 6 Vet. App. 465 (1994) (concluding that lay witnesses are competent to provide testimony or statements relating to facts of events that the lay witness observed and is within the realm of his/her personal knowledge). Service treatment records are silent with respect to immunization method of delivery. However, "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The absence of such evidence is simply one factor among many others, such as possible bias and conflicting statements, that may be considered in evaluating the credibility of lay evidence. Id.; see also Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that the credibility of lay evidence generally can be evaluated by a showing of interest, bias, or inconsistent statements); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor can be factors to determine lay evidence credibility). The Veteran is self-interested given that a favorable outcome will result in monetary compensation. Yet, no conflicting or inconsistent statements are of record. Furthermore, facial implausibility is not an issue, as VA has recognized that immunizations sometimes were provided with air guns. Weighing these factors, the Veteran is found to be not only competent, but also credible in stating that he received immunizations via air gun during service. This in-service risk factor therefore has been established. The Veteran has not specifically asserted that he had any other risk factors other than the aforementioned in-service air gun immunizations. However, additional risk factors are shown by the evidence of record. One risk factor shown in the medical evidence of record is the Veteran having engaged in unprotected sexual intercourse. The Veteran is competent to report whether he engaged in high-risk sexual activity or not because whether or not he engages in safe sexual practices is within his personal experience. At the time that the Veteran filed his claim, he did not report having engaged in any unsafe sexual activities. Later in 2000, he requested testing for a sexually transmitted virus and reported having unprotected sex with multiple partners. The Board finds that the Veteran's reports are also credible, in that there is no contradictory evidence of record to refute his claims. The Veteran has not claimed, nor does the evidence indicate, that the Veteran engaged in risky sexual practices during his active duty service. As there is no evidence that indicates otherwise, high risk sexual activity is not established as an in-service risk factor. The Board acknowledges the Veteran's reports of acquiring several tattoos during his military service. The Board recognizes that tattoos are a recognized risk factor. Yet, the evidence does not show that the Veteran's tattoos were produced using contaminated needles, nor does the Veteran claim such an occurrence. Moreover, it does not appear that there is any information or procurable data to confirm any such allegations. The Veteran has not presented any information that he was exposed to hepatitis C from his in-service tattoos from the use of contaminated equipment. Thus, the Veteran's in-service tattoos are not established as an in-service risk factor. Specifically denied by the Veteran was intravenous drug use, one of the highest prevalence risk factors. For the reasons noted above, he is competent to report that he did not engage in intravenous drug use. He also is credible in this regard as, like above, no reason is found to doubt him. There is no evidence or history that the Veteran engaged in intravenous drug use. In this case, service connection turns on whether the Veteran's current hepatitis C disability is attributable to the only established in-service risk factor, specifically the in-service receipt of immunizations via air gun injection. The weight of the evidence does not show this to be the case. The medical evidence contains multiple opinions regarding whether the Veteran's hepatitis C is related to the in-service administration of immunizations, via the use of air gun injectors. However, the preponderance of the medical evidence is negative for a medical opinion relating the Veteran's hepatitis C to the claimed in-service risk factor. Here, the Board notes that the VA examiner who conducted the October 2010 VA examination initially opined that the Veteran's hepatitis C was related to his in-service immunizations through the use of an air gun injector. However, the Board also notes that the VA examiner did not provide a basis for this opinion, and in a December 2011 addendum report, he reversed his favorable opinion and determined that it was less likely than not that the Veteran's hepatitis C was incurred or caused by jet injector immunizations during the Veteran's military service. The August 2011 VA examiner similarly opined that the Veteran's hepatitis C was not related to the in-service jet injector immunizations. Due to the conflicting and contradictory nature of the VA examiners' opinions, and the fact that the October 2010 opinion did not include a rationale; the Board found that the opinions were of limited probative value. Consequently, the aforementioned VHA opinion was requested. The November 2012 opinion of the VHA specialist is considered highly probative as it is definitive, based upon a complete review of the Veteran's entire claims file and/or clinical examinations of the Veteran, and supported by a detailed rationale. Accordingly, the Board finds that the November 2012 VHA opinion is the most probative regarding the issue of the etiology of the Veteran's hepatitis C disability. Here, the Board notes VA's reliance on a medical opinion requires a finding that that the conclusion was made after consideration of "all procurable and assembled data." Jones v. Shinseki, 23 Vet. App. 382 (2010). Reliance on an examiner's opinion further requires that the basis for it be provided or otherwise be apparent from a review of the record. Id. Factors for assessing the probative value of a medical opinion indeed include the examiner's access to the claims file and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444 (2000). Here, the claims file containing service treatment records, post-service treatment records, and statements from the Veteran was reviewed by the VHA specialist prior to the opinion being rendered. In this regard, although the VHA specialist did not specifically state that he had reviewed the Veteran's claims file, the fact that he discussed relevant evidence found in the claims file, including the Veteran's reported history, supports a conclusion that he did have access to and did review the claims file prior to rendering his opinion. It follows that "all assembled data" was considered. To reiterate an above finding, the duty to assist has been fulfilled such that no additional development is warranted. Research in medical literature further was undertaken. It follows that "all procurable data" was considered. In rendering the November 2012 opinion, the VHA specialist discussed the medical literature relevant to the risks associated with the military's use of jet injectors, and/or the most common transmission risk factors, and the likelihood of transmission based on the alleged in-service risk factors and the post-service risk factors, as set forth above. Thus, the basis for the November 2012 opinion was clearly set forth. Because the two aforementioned requirements have been met, the Board may rely on the November 2012 VHA specialist opinion. No probative medical opinion countering this opinion has been submitted in support of the Veteran's claim. The only other evidence doing so indeed is lay evidence. Specifically, the Veteran believes that his hepatitis C is attributable to one of his in-service risk factors. At issue, then, is whether the Veteran is competent in asserting his belief that his hepatitis C is attributable to in-service jet injector immunizations. The Board concludes that the Veteran is a layperson, who is not qualified to opine on the etiology of a medical disorder. "Explicitly rejected [is] the view ... that "competent medical evidence is required ... [when] the determinative issue involves ... medical etiology.'"' Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), and referencing Buchanan v. Nicholson, 451 F.3d 1131 (Fed. Cir. 2006) for the proposition that "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "[L]ay evidence is one type of evidence that must be considered." Buchanan, 451 F.3d at 1331. "[C]ompetent lay evidence [indeed] can be sufficient in and of itself." Id. The Veteran is competent, as a lay person, to report that as to which he has personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). However, the question of whether there is a service etiology in this case is medical in nature given the complexities involved. Noted in this regard is the number of years that passed between the Veteran's service and his diagnosis with hepatitis C, the number of risk factors involved, and the fact that some of these are in-service risk factors and some are not. The Veteran is not competent to offer a medical opinion as to the cause or etiology of the claimed disability, as there is no evidence of record that he has specialized medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997) (layperson is generally not capable of opinion on matter requiring medical knowledge); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The lay statements of the Veteran are not competent medical evidence as to a nexus between the Veteran's hepatitis C disease and his service or as to the etiology of his hepatitis C. Even if the Board were to find the Veteran competent regarding his belief that the origin of his hepatitis C relates to his service, "the Board retains discretion to make credibility determinations." Jandreau, 492 F.3d at 1372 (discussing Buchanan, 451 F.3d at 1331. The Board does not find him to be credible. That his belief that his hepatitis C is etiologically related to his service is unsupported by any medical evidence is just one factor leading to this conclusion. Another factor is the inconsistent statements he has given. In December 1996, the Veteran essentially reported that he was diagnosed with hepatitis C prior to his 1994 lung surgery. During the pendency of the claim, however, he indicated that he first experienced hepatitis symptomatology during service. This raises a third factor, when he first asserted his belief. The record reflects that hepatitis C was diagnosed in December 1996. Yet absent from the record is any indication, to include from the Veteran, that this condition was due to service until the instant claim was filed in January 2002. It thus appears that his belief was asserted in an attempt to secure VA benefits, a final factor against his credibility. See Cartright v. Derwinski, 2 Vet. App. 24 (1991) (holding that a Veteran's personal interest in receiving monetary benefits may be taken into account). Even if the Board were to find the Veteran both competent and credible regarding his belief, "the Board retains discretion to ... weigh the evidence submitted, including lay evidence." Jandreau, 492 F.3d at 1372 (discussing Buchanan, 451 F.3d at 1331). The Board finds that the evidence weighs against service connection. Substantial probative weight is afforded to the August 2011, December 2011 and November 2012 opinions, which did not find an in-service etiology. This is because these opinions involved thorough explanations, were rendered by physicians, and were rendered after review of the claims file and consultation with medical literature. The Veteran's belief, which posits an in-service etiology, contrastingly is afforded little probative weight. This is for a few reasons. First of all, the Veteran's belief is nothing more than a conclusory declaration. It was not explained at all. In a single judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252 (1992). Furthermore, the Veteran is not a physician and did not review any relevant information. It may be argued that he need not review the claims file since it contains documentation of his medical history of which he is aware through personal experience. Yet, this argument does not apply to the review of medical literature. Moving on, several reasons are found for rejecting continuity of symptomatology as a viable theory of entitlement in this case. Neither a hepatitis diagnosis, nor symptoms associated therewith, was noted during service, as discussed above. Similarly, there is no evidence that the Veteran has had hepatitis C, or has had symptoms associated with virus since service. As noted above, hepatitis C was first diagnosed in December 1996. There is also no indication that the Veteran was seen or treated for symptoms associated with hepatitis C prior to this date. A prolonged period without medical complaint can be considered in analyzing a service connection claim. Maxson v. West, 12 Vet. App. 452 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). In sum, the preponderance of the evidence is against the Veteran's claim of entitlement to direct service connection, through continuity of symptomatology, or otherwise, for hepatitis C. The doctrine of reasonable doubt thus is not applicable, and the claim is denied. Legal Criteria for § 1151 Claims The applicable version of 38 U.S.C.A. § 1151 provides, in pertinent part, that a Veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. Under the law, in order to establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the Veteran's additional disability. 38 C.F.R. § 3.361(c)(1). Merely showing that a Veteran received care, treatment, or examination, and that he has additional disability, does not establish cause. Id. In determining whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran's condition after such care or treatment. See 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in a Veteran's additional disability. Merely showing that a Veteran received care or treatment and that the Veteran has an additional disability does not establish cause. See 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. See 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 1.7.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. See 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2). Pursuant to the language of the aforementioned law and regulation, section 1151 claims for additional disability are treated similarly to claims for service connection. See Jones v. West, 12 Vet. App. 383 (1999); Boggs v. West, 11 Vet. App. 334 (1998). Hence, to establish entitlement, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of incurrence or aggravation of an injury as the result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation under Chapter 31 of title 38, United States Code; and (3) medical evidence of a nexus between that asserted injury or disease and the current disability. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Although all the evidence has been reviewed, only the most salient and relevant evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Analysis- § 1151 Claim Having reviewed the claims file in light of the foregoing regulations, the Board finds that the evidence is against the claim for compensation for hepatitis C under the provisions of § 1151. The record shows that the Veteran has been diagnosed with hepatitis C since December 1996. The record also shows that the Veteran underwent lung surgery in November 1994. However, the clinical evidence of record does not show that the Veteran's hepatitis C was caused by carelessness, negligence, lack of proper skill, error in judgment, or any other similar instance of fault on the part of VA providing hospital care or surgical treatment to the Veteran. Therefore, there is no basis to grant the Veteran's claim in this instance. The Veteran first claims that his hepatitis C is due to a blood transfusion he received in connection with his November 1994 lung surgery at a VA medical facility. The Board notes that the Veteran is competent to report that he was treated at a VAMC medical facility. The Board also acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, but such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of Veteran's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). However, in the present case, there is no supporting evidence, whatsoever, in the claims file that the Veteran had a blood transfusion at a VAMC. The intraoperative report, anesthesia report, and in-patient treatment records associated with the November 1994 lung surgery have been reviewed and are completely negative for any evidence that the Veteran received a blood transfusion prior to, during, or subsequent to his VAMC lung surgery. Moreover, the Veteran has not provided any clinical or independent evidence of a blood transfusion at the VAMC. Given this, his claim that he received a blood transfusion in connection with his November 1994 lung surgery is not credible. Additionally, the Board has considered the Veteran's claim that VAMC personnel acted negligently during in-patient treatment associated with his lung surgery. As noted above, he claims that a chest tube was improperly inserted prior to his surgery and that the VA medical personnel provided treatment without using gloves. While the Veteran is competent to describe his treatment at the VAMC, there is simply no evidence of record to corroborate his reports of negligence at the hands of VAMC personnel. See generally, Washington v. Nicholson, 19 Vet. App. 362, 368 (2005), (holding that a Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge). Indeed, the December 1994 discharge summary, along with all other associated medical evidence, indicates that the Veteran tolerated the November 1994 lung surgery well and that the associated in-patient treatment he received was without incident. A November 1994 VA chest X-ray examination did reveal the presence of a kinked chest tube prior to the Veteran's lung surgery. However, there is no objective evidence that this was attributable to negligence or improper care. Essentially, the Board does not find the Veteran's allegations of negligence and improper care to be credible in this instance, as they are contradicted by the medical evidence of record. Moreover, even if the Veteran was found credible with regard to his report of a blood transfusion and negligent/improper care at a VAMC in 1994, he is not competent to report that he contracted hepatitis C from any such treatment. The Veteran's contentions notwithstanding, there is no persuasive evidence to support a finding that his hepatitis C is etiologically related to VA medical treatment. Although the Veteran is competent to testify as to his experiences and symptoms, where the determinative issue involves a question of medical diagnosis or causation, only individuals possessing specialized medical training and knowledge are competent to render such an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The evidence does not reflect that the Veteran currently possesses a recognized degree of medical knowledge that would render his opinions on medical diagnoses or causation competent. See Washington v. Nicholson, 19 Vet. App. 362 (2005), citing Layno v. Brown, 6 Vet. App. 465, 469-71 91994) (holding that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witness' personal knowledge). The Veteran is not competent to provide an opinion as to whether he has additional disability as a result of VA treatment (or lack thereof) due to negligence or lack of proper care. Turning to the competent medical evidence of record, the Board finds the November 2005 VA examiner's opinion the most probative evidence with regards to the § 1151 claim. The Court has held that "a medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Court has also indicated that in evaluating the medical opinion evidence, (1) the testimony is based upon sufficient facts or data; (2) the testimony is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliably to the facts of the case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, the November 2005 VA examiner reviewed the Veteran's claims file, took a history, considered his lay statements, and conducted a physical examination. Based on the information gathered from the clinical examination and the review of the claims file, the November 2005 examiner rendered her opinion against the Veteran's claim. Accordingly, the opinion is found to carry significant probative weight. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Veteran has not provided any competent medical evidence to rebut the opinion against his claim or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). As noted above, merely showing that a Veteran received care, treatment, or examination and that the Veteran has an additional disability does not establish causation. See 38 C.F.R. § 3.361(c)(1). In the present case, there is no clinical evidence that the Veteran's chronic hepatitis C disease is the proximate result of the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing care or treatment. The evidence of record does not show that the Veteran's disability was due to a failure by VA to exercise the degree of care that would be expected of a reasonable health care provider or that VA furnished hospital care, medical or surgical treatment, or examination without the informed consent of the Veteran, or if applicable, his representative. See 38 C.F.R. § 3.361(c), (d)(1). Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of compensation for hepatitis C disease under 38 U.S.C.A. § 1151. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Service connection for hepatitis C is denied. Compensation pursuant to 38 U.S.C.A. § 1151 for hepatitis C, claimed as due to VA lung surgery and associated in-patient treatment in November 1994, is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs