Citation Nr: 1507259 Decision Date: 02/19/15 Archive Date: 02/26/15 DOCKET NO. 13-04 414 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to service connection for hepatitis C. REPRESENTATION Veteran represented by: Keith D. Snyder, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and Spouse ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from March 1981 to March 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. This rating decision confirmed and continued the denial of the Veteran's claim by the Providence, Rhode Island RO in a March 2010 rating decision. In September 2014, the Veteran testified during a Board hearing before the undersigned Acting Veterans Law Judge; a transcript of the hearing has been associated with the record. The Board observes that the Veteran also requested a hearing before a Decision Review Officer at the RO. However, as this decision represents a full grant of the benefits on appeal, a remand for such a hearing is unnecessary. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. FINDINGS OF FACT 1. The Veteran had multiple jet injector inoculations in service; the Veteran also underwent a dental procedure in service. 2. Hepatitis C is attributable to service. CONCLUSION OF LAW Hepatitis C was incurred in service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION As the Board is granting service connection for hepatitis C in this decision, further discussion of VA's duties to notify and assist is unnecessary as any error on VA's part would be harmless. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2014). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnoses related to hepatitis C. Upon entrance into service, a dental record reflects that the Veteran did not have hepatitis or liver problems. In April 1981, she underwent an extraction of four teeth. Between March 1981 and May 1981, the Veteran received inoculations. In August 1981, she was treated for a rash. In June 1981 and April 1984, the Veteran was seen for pain of the lower right quadrant of her abdomen; a history of pelvic inflammatory disease and ovarian cyst were noted. On her February 1985 Report of Medical History, the Veteran complained of swollen or painful joints and stomach or liver problems. The contemporaneous separation examination was normal; a tattoo on her right hand was noted. A January 2009 letter from Dr. V indicates that the Veteran denied all risk factors other than serial jet injector inoculations during her service; the Veteran did not have any blood transfusions or intravenous drug use. An August 2009 VA examination report indicates that the Veteran was first diagnosed with hepatitis C in 1990; she first noticed symptoms of fatigue and abdominal pain in 1989. Risk factors include jet injector inoculations, dental work, and a tattoo that the Veteran did herself at age 12. The VA examiner, in a February 2010 addendum, indicated that the Veteran's hepatitis C could not be attributed to service without resorting to speculation; the VA examiner's rationale was that hepatitis C was not shown in service and she was not diagnosed until 1990. A September 2011 VA examination report acknowledged that the jet injector inoculations were a possible risk factor for hepatitis C exposure, but that the Veteran's hepatitis C was likely related to her tattoo or her pelvic inflammatory disease. August 2011 and February 2012 letters from Dr. S at Johns Hopkins indicate that, following a review of the Veteran's medical records, the only risk factors she had were the jet inoculator vaccinations and oral surgery during her service, and that her hepatitis C was more likely than not due to cross contamination during either or both procedures. Dr. S noted that the route of infection to cirrhotic decompensation left the military jet injector inoculation as the most likely source of her hepatitis C infection. In May 2012, the Veteran submitted a copy of a Department of the Air Force report indicating that jet injector vaccinations were discontinued in 1997 due to transmission of blood-borne pathogens. An October 2012 VA examination report indicates that the VA examiner reviewed the Veteran's service treatment records, and following an examination and review of post-service treatment records, the examiner noted that the Veteran was diagnosed with liver cancer in July 2011. The VA examiner concluded that it was not at least as likely as not that the Veteran's hepatitis C was related to service, as there was no scientific evidence that her jet injector inoculations caused her hepatitis C. The VA examiner noted that the exchange of blood products before 1992 is considered a risk factor. A March 2013 letter from Dr. C of the Hepatitis C Treatment Centers indicates that there were symptoms of the Veteran's hepatitis C prior to discharge, namely, the abdominal pain, rash, and joint pain shown in her treatment records and at separation; he noted that there was no blood test for hepatitis C until 1989. Dr. C indicated that the Veteran's air gun vaccinations were the most likely risk factor for her hepatitis, and that the time frame for hepatitis C exposure to liver cancer was 30 years, which was in line with the time frame of in-service exposure and the diagnosis of her liver cancer. Doctor C wrote a similar letter in January 2012. A December 2013 letter from Dr. H at Johns Hopkins states that the Veteran's only risk factor for her hepatitis C was her Navy service. Dr. H indicated that the Veteran's hepatitis C recurred despite her liver transplant. As previously indicated, the Veteran appeared before the undersigned in September 2014. At that time, the Veteran and her husband testified that she was first diagnosed with hepatitis C in 1990 and liver cancer in July 2011, for which she underwent a liver transplant; her hepatitis C nevertheless recurred after the transplant. The Veteran also testified that she did not engage in any risk factors such as intravenous drug use or sexual promiscuity. The Veteran testified that she bled, and was exposed to other people's blood, during the jet injector inoculations when there was a mass vaccination at basic training; she also testified that there was a lot of bleeding when she had her teeth extracted in service. The Board observes that the Veteran has consistently claimed that her hepatitis C is due to an exposure to blood during mass jet injector inoculations in service or dental instruments related to the extraction of four teeth during service. In this case, the Board finds that at a very minimum, the evidence is in equipoise; there is positive and negative evidence. The Board is presented with the lay pleadings, and the Veteran's reports to the VA examiners and her treating providers; the Board finds these statements to be competent and credible. Likewise, the Veteran's pleadings are consistent with those of her treating providers, who found that her jet injector inoculations and oral surgery were the most likely etiological risk factors of her recurrent hepatitis C and related liver cancer. Although the VA examiners found that the Veteran's hepatitis C was not likely related to any event during the Veteran's service, the examiners were unable to link the hepatitis C to any particular post service event. The fact that the Veteran had pelvic inflammatory disease or did her own tattoo at age 12 are irrelevant, and the Veteran's treating physicians have concluded that such events are unlikely sources of her hepatitis C, as they did not involve the transmission of blood. The Veteran's treating providers also point out that the Veteran did not have intravenous drug use or any other high risk factors for hepatitis C, and that the time of inoculation at entrance into service is consistent with the timeframe of the diagnosis of the Veteran's hepatitis C and liver cancer; the Board finds the opinions of the Veteran's treating providers to be of higher probative value than those of the VA examiners. Nonetheless, the Board also notes that VA examiners conceded that jet injector inoculations and oral surgery are possible risk factors for hepatitis C, which is consistent with the opinions of the Veteran's treating providers. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, a nexus has been established between her in-service risk factors and her hepatitis C diagnosis. Accordingly, service connection for hepatitis C is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for hepatitis C is granted. ____________________________________________ Nathan Kroes Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs