Citation Nr: 19138445 Decision Date: 05/17/19 Archive Date: 05/17/19 DOCKET NO. 16-10 361 DATE: May 17, 2019 ORDER Entitlement to service connection for Hepatitis C is denied. FINDING OF FACT The preponderance of the evidence is against finding that Hepatitis C began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for Hepatitis C are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1974 to December 1976. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131(2012); 38 C.F.R. § 3.303(a) (2018). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Entitlement to service connection for Hepatitis C The Veteran contends that her Hepatitis C is the result of her active service. Specifically, she contends that she contracted Hepatitis C during an inoculation. Service treatment records (STRs) indicates a 15-day hospitalization during March and April 1975 where a diagnosis of “Hepatitis, type B, HAA positive (HAA converted to negative 24 March 1975)” was made. In a subsequent April 1975 inpatient treatment note, there was an assessment of hepatitis, type B, HAA positive. The first indication in the record of a Hepatitis C diagnosis occurs in a January 2002 private consultation from Dr. M.B. with an impression of probable chronic Hepatitis C. In January 2016, the Veteran attended a VA Hepatitis, Cirrhosis, and other Liver Conditions Disability Benefits Questionnaire (DBQ) examination. In an accompanying Hepatitis C risk assessment questionnaire, the Veteran answered positive to a history of IV drug use, snorting cocaine, risky sexual behavior, and employment as a psychiatric technician assigned to a male detox and hepatitis ward. The examiner diagnosed Hepatitis C and opined that the condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was: … After careful review of the claim file medical records, review of the [V]eteran’s statement on her risk factors for contracting hepatitis C virus while active duty, weighing the list of positive risk factors noted on the Hepatitis risk factor questionnaire completed today against the risk factors published in the medical literature to include evidence from the CDC website, in consideration that the [V]eteran's history is positive the risky behavior to include IV drug use and ETOH abuse after her discharge from active duty, in consideration that the medical literature indicates that IV drug use is the leading cause of HCV infection in the US, and in consideration that the potential for contracting hepatitis C virus from an inoculation gun remains controversial according to the medical literature, it is this examiner's opinion the [V]eteran's current chronic HCV condition is less likely than not due to or caused by any event or activity that occurred while she was active duty. Review of the medical records indicates that the [V]eteran was hospitalized March 12, 1975 through April 4, 1975 for hepatitis type B HAA positive. According to the medical record lab work was completed and a D&C was performed during her hospital stay. Being that these procedures were conducted in a hospital environment where measures are employed to minimize contracting infections during invasive procedures it is not likely that she was exposed to the hepatitis C virus during her convalescence for Hep B while active duty. In a February 2016 medical correspondence, Dr. M.B. indicated that he treated the Veteran in 2002-2003 for Hepatitis C with Interferon and Ribavirin. Further, he stated that the Veteran: contracted hepatitis while in the service after receiving air gun inoculations and spending time working in a hospital although with the latter there is no history of any needle exposures. She had no history of IV drug use prior to this episode of hepatitis. I have reviewed the record from March of 1975 at 97 General Hospital in Frankfort Germany. The record indicates the following: She was hospitalized for hepatitis at that time. The patient recalls being told by the attending physician that she had non-A, non-B hepatitis. There Is a mention in the discharge summary that this was type B hepatitis but there is absolutely no documentation in any of the record of a hepatitis B positive serology. Therefore, in my opinion it appears that the physician who dictated that discharge only made a presumptive diagnosis of hepatitis B without any documentation. She clearly however has shown up with hepatitis C positive serology when that became available. I think it therefore more likely that she had actually non-A, non-B hepatitis related to the air gun inoculation at that time in 1975. In summary, if there were documentation of a positive hepatitis B serology at the time she was hospitalized in 1975 then I think that your findings would be correct. However, there was no documentation of that and she has had subsequent serologies which do not indicate any evidence of hepatitis B. Typically hepatitis B serologies remain positive indefinitely although occasionally can be lost. Nevertheless, given her negative hepatitis serologies, her lack of documentation of any positive hepatitis B serology in 1975, and likely an erroneous presumption that she had hepatitis B in 1975 by the discharging physician, I believe that your findings are in error and that she actually did contract non-A, non-B now known as hepatitis C at the time of her service related to the air gun inoculation. I therefore think that your assessment is erroneous and requires revision. In August 2016, as a result of the foregoing conflicting medical opinions, another VA medical opinion was provided. After a complete review of the Veteran’s claims file, this person opined as follows: This examiner has evaluated the C and P note from Jan 2016 and Dr M. B.’s letter from Feb 2016, as well as the STRs. Dr. M.B. states that he had treated the vet in 2002 and 2003 for HCV. He opines that the Veteran contracted HCV from the air gun inoculations or while working in a hospital, although the vet did not have needle exposure. STRs demonstrate a hospitalization in Mar 1975 for hepatitis. At that time it was noted that the HAA blood test was positive, and she was also given a diagnosis of hepatitis B. However, the HAA test is used to differentiate alcoholic hepatitis from non-alcoholic. A positive test argues in favor of alcoholic hepatitis. The test converted to negative within 10 days, which would be expected in the setting of no alcohol consumption. Veteran received vaccinations from Jan-Jul of 1974. The medical literature is outlined by the C and P examiner in the Jan 2016 exam regarding statements on the possibility of transmitting HCV via air gun inoculators and is "controversial". None the less, acute hepatitis C is not common, only about 15% of cases show symptoms in the acute phase. Those symptoms occur 2-26 weeks after presumed exposure, with a mean onset of 7-8 weeks. Even 26 weeks is beyond the last documented vaccination date of Jul 1974 till March 1975. The Veteran admits to other more significant risk factors, namely a history of IV drug use. Given the lack of medical evidence for air gun inoculators transmitting HCV, given the positive HAA blood test at the time of the hospitalization as an explanation for the hepatitis, given the length of time between the last documented vaccination and the onset of hepatitis symptoms, it is less likely than not that the Veteran had HCV during that hospitalization or that she contracted it while in the service. Numerous VA treatment records indicate treatment for hepatitis but no discussion on its etiology. Based on the foregoing evidence of record, the Board finds that service connection is not warranted for Hepatitis C. Indeed, the earliest indication of a diagnosis occurs in 2002, more than 25 years after the Veteran left active service. Further, the Board finds the January 2016 and August 2016 opinions the most probative of record because they were based on an accurate medical history and provided explanations that contain clear conclusions and supporting data. It is unclear if the provider of the private medical opinion reviewed the Veteran’s entire claims file, as it notes the opinion was provided after he reviewed “the record from March of 1975 at 97 General Hospital in Frankfort Germany” and the provider seems to have been unaware of the actual in-service diagnosis, relying instead on what the Veteran reportedly remembered. As such, this opinion is accorded less weight. The Board has considered the Veteran’s lay assertions as to the etiology of her condition. Although the Veteran is competent to attest to her experiences, she is not competent in these circumstances to opine as to the etiology of her hepatitis C. The Veteran has not been shown to have specialized medical knowledge that would be necessary to provide a competent opinion regarding service connection. The Board finds the opinions of the January 2016 and August 2016 examiners to be more probative in this regard. The examiners considered the Veteran’s history, and ultimately concluded that from a medical perspective, it is less likely that her current disability is related to service. Further, the VA examiner provided the likely etiology of the Veteran’s hepatitis C. In conclusion, the weight of the evidence is against the claim for service connection for hepatitis C. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R.A. Elliott II, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.