Citation Nr: 1829640 Decision Date: 07/11/18 Archive Date: 07/24/18 DOCKET NO. 14-32 288A ) 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: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from May 1962 to May 1965 in the United States Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 2017, the Veteran withdrew his request for a Board hearing. FINDING OF FACT Hepatitis C is not attributable to service. CONCLUSION OF LAW The criteria for entitlement to service connection for Hepatitis C have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION In reaching the decision below, the Board considered the Veteran's claim and decided entitlement based on the evidence. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to show a service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The Veteran has current Hepatitis C, documented on VA examination in August 2014. Medically recognized risk factors for hepatitis C include: (a) transfusion of blood or blood product before 1992; (b) organ transplant before 1992; (c) hemodialysis; (d) tattoos; (e) body piercing; (f) intravenous drug use (with the use of shared instruments); (g) high-risk sexual activity; (h) intranasal cocaine use (also with the use of shared instruments); (i) accidental exposure to blood products as a healthcare worker, combat medic, or corpsman by percutaneous (through the skin) exposure or on mucous membrane; and (j) other direct percutaneous exposure to blood, such as by acupuncture with non-sterile needles, or the sharing of toothbrushes or shaving razors. See M21-1, III.iv.4.l.2.e. The Veteran reports he contracted Hepatitis C during service via air gun inoculation. He states he had to stand in a line with 40-50 other men to receive immunizations, and that many were bleeding from the site of injection. He states that his friend, who has since passed away, stood in line with him and also had Hepatitis C during his lifetime. He also states that while he had surgery during service, he does not feel he contracted Hepatitis C from the operation. See, e.g., February 2011 & October 2012 VA Forms 21-4138. Regarding immunization with a jet air gun injector, information in VA's training materials, the M21-1, indicates that despite the lack of any scientific evidence to document transmission of the Hepatitis C virus with air gun injectors, it is biologically possible. A medical report linking hepatitis to air gun injectors must include a full discussion of all potential modes of transmission and a rationale as to why the examiner believes the air gun injector was the source for the hepatitis infection. See M21-1, III.iv.4.l.2.e. On his May 1962 service entrance examination, neither Hepatitis C nor problems with the liver were noted. Tattoos and body piercings were not noted. Service treatment records (STRs) do not document complaints, diagnoses, or treatment relating to the Veteran's liver or Hepatitis C. The Veteran received several immunizations during service, as shown by his Immunization Record. The Immunization Record does not reveal any adverse reactions to any immunization. In April 1965, he underwent elective surgery for a circumcision; a blood transfusion was not received during the procedure. No other risk factors were noted during service. On his May 1965 separation examination, Hepatitis C was not noted and no abnormalities were found involving the liver, including on laboratory findings. Tattoos and body piercings were not noted. The Veteran reported no pertinent complaints on the accompanying Report of Medical History. His DD Form 214 shows that his military occupational specialty was an automobile mechanic. There were no records showing complaints, a diagnosis, or treatment of Hepatitis C in close proximity to discharge from service. Private medical records indicate the condition was diagnosed in approximately 1981. In an August 2011 letter, Dr. M., the Veteran's treating physician indicated that the Veteran underwent a series of vaccinations and underwent a circumcision surgery during his active military service. He concluded, "the patient states that he has no other known risk factors for hepatitis C infection." In an August 2014 VA medical opinion, the examiner reviewed the claims file and addressed the matters of both the in-service surgery and the air gun inoculations. He opined that the Veteran's Hepatitis C was less likely than not caused by or a result of military service, including the surgery. The surgery was performed in a stateside facility where standard sterilization procedures for the surgical instruments would have thoroughly decontaminated them from Hepatitis C or other pathogens. As such, the risk of Hepatitis C from this operation was negligible. Additionally, the Veteran did not receive any blood transfusions during the procedure. The examiner also opined that the Veteran's Hepatitis C was less likely than not caused by or a result of air gun inoculations during service. He explained the mechanisms of a jet injector, stating that there is high-pressure injection of the liquid rather than via hypodermic needle. There have been relatively few incidents of disease transmission between users, despite widespread use of the jet injector by the military and large-scale vaccination campaigns. Nonetheless, because the jet injector does break the barrier of the skin, there is a potential for biological material to transfer from one user to the next. However, medical literature indicates an extremely low, 0.5-1.8 percent, transmission rate. It is known from the medical literature that the source of infection is unknown in anywhere from 10 to 44 percent of Hepatitis C cases. The examiner stated there are clearly other, currently unidentified modes of transmission, which may be the case for the Veteran. The examiner provided citation to medical literature in support. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claim. The probative evidence does not show that the Veteran's Hepatitis C is related to his active military service, including to the air gun inoculations or in-service surgery. The disorder was not found in service or within one year of separation from service; rather, the evidence reflects that the disorder was not shown until many years after service discharge. There were no pertinent abnormalities at discharge examination and no related complaints. The medical opinion evidence is also persuasive. The August 2014 VA examiner addressed the contentions of direct service connection, but opined that the Veteran's Hepatitis C was not related to military service based on a discussion of his individual risk factors and medical literature. The examiner based his conclusions on an examination of the claims file, including the post-service treatment records and diagnostic reports. He reviewed the reported history and symptoms in rendering the opinions, and provided a rationale for the conclusions reached. The August 2011 report of Dr. M. is of low probative value because it does not set forth an actual medical opinion with a rationale. Rather, the note merely documents the Veteran's reports of his risk factors. The report does not ascribe Hepatitis C to those risk factors or military service. The only evidence to the contrary of the VA examination reports is the lay evidence. The Board finds that, under the facts of this case, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders such as Hepatitis C. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury). Hepatitis C is a medically complex disease processes because of its multiple etiologies, requires specialized testing to diagnose, and manifests symptomatology that overlaps with other disorders. The etiology of the Veteran's current Hepatitis C is a complex medical etiological question involving internal and unseen system processes, some of which are unobservable by the Veteran. To the extent the Veteran asserts there is prior Board precedent permitting service connection for Hepatitis C based on air gun inoculation, other Board decisions have no precedential value as each case is decided on the basis of the individual facts presented. 38 C.F.R. § 20.1303. The Board has considered the applicability of the benefit of the doubt doctrine, but as the preponderance of the evidence is against the Veteran's claim for service connection for Hepatitis C, that doctrine is not applicable to the claim. ORDER Service connection for Hepatitis C is denied. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs