Citation Nr: 21073359 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 15-31 702 DATE: December 8, 2021 REMANDED Entitlement to service connection for hepatitis C is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1976 to March 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in December 2018. A transcript of the hearing is of record. This matter was previously before the Board in July 2019 and March 2021 when it was remanded for further development. Entitlement to service connection for hepatitis C is remanded. Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made on the Veteran's claim. In accordance with the March 2021 Board remand, a medical opinion addressing the etiology of the Veteran's condition was obtained. In the April 2021 opinion, the examiner opined that the Veteran's hepatitis C was not related to his active service, including air gun inoculations. In the opinion, the examiner first acknowledged March 2021 Board remand order instructions to find the Veteran's claims that he never shared needles when using intravenous (IV) drugs credible; therefore, the examiner concluded that the Veteran could not have acquired hepatitis C from using IV drugs. However, the examiner explained that, per UpToDate medical literature, there are other risk factors that could have been the cause of the Veteran's hepatitis C, including sex with an IV drug user, having been in jail for more than three days, and having been struck or cut with a bloody object. Regarding the first risk factor, sex with an IV drug user, the examiner noted that the Veteran reported being homeless a few times for various durations and that he used illegal drugs, including cocaine, crack, methamphetamine, marijuana, and other drugs, during that time. The examiner noted that it is well-documented in medical literature that illegal drug users tend to be more promiscuous and indiscriminate in their sexual encounters/partners resulting in greater chances of acquiring sexually transmitted diseases and infections along with hepatitis B, hepatitis C, and HIV. This, the examiner explained, is due to illegal drug users, especially those who use IV drugs, having psychiatric and personality disorders which result in increased risk of dangerous behaviors, including trading sex for drugs. The examiner indicated that being homeless only increases those risks. The examiner noted that there were times the Veteran was homeless and that he might have had sexual intercourse with IV drug users who shared needles, noting that it is medically documented that he had genital herpes which might have also been a result of his periods of reckless sexual activities. Additionally, the examiner indicated that a study conducted by the National Institute of Health found methamphetamine misuse raises the risk of contracting or transmitting hepatitis C as it is associated with a culture of risky sexual behavior. As for the second risk factor noted above, having been in jail more than three days, the examiner noted that the Veteran's records reflect that he had been arrested multiple times. Lastly, for the third risk factor noted above, having been struck or cut with a bloody object, the examiner noted that the record indicates that the Veteran reported putting his hand through a drive-thru window and that he had been stabbed, hit in the head with a brick, and cut with beer bottles. The examiner then addressed the Veteran's claims of contracting hepatitis C from the air gun inoculations he received during service. The examiner explained that the possibility of the tip of the air gun injector being contaminated with back flow of blood from a prior recipient is possible, but the theoretical possibility of the Veteran acquiring hepatitis C from an infected person ahead of him is remote. First, the examiner explained, the infected person would have needed to have a significant viral load high enough to be transferred in such a short contact time or amount of blood. To have such a viral load, the infected person would most likely have manifested symptoms, such as jaundice and fatigue, and, if so, would not have passed the enlistment physical. Second, the Veteran would have had to be right behind the infected person. Third, although back flow of injected fluid into the air gun injector is possible in a laboratory setting, there has been no known peer reviewed medical literature supporting such a live infection transmission. Thus, the examiner explained that the possibility of the Veteran being infected with hepatitis C during air gun inoculations is remotely small, especially when compared to other risk factors. The examiner then concluded that it's more likely the Veteran contracted hepatitis C due to the aforementioned three risk factors as opposed to the remote possibility of contracting it from the air gun inoculations. However, the Board finds the opinion inadequate. The examiner indicated that the Veteran had other risk factors for contracting hepatitis C, including (i) sex with an IV drug user, (ii) having been in jail for more than three days, and (iii) having been struck or cut with a bloody object. However, while the record does indicate the Veteran had been arrested, there's no evidence he spent more than three days in jail. Additionally, despite the evidence indicating the Veteran cut both arms (one on a drive-thru window and the other from a beer bottle) there is no evidence of record indicating that the Veteran was struck with a bloody object. Although the examiner indicated that he was considering the Veteran's statement regarding not sharing needles when engaging in IV drug use to be credible as the Board's remand had requested, the opinion otherwise indicates that the examiner did not find the Veteran's statements to be credible; therefore, it is unclear whether the opinion substantially complied with the Board's request in this regard. In light of this, the Board finds the opinion inadequate and remand for a new medical opinion is warranted. The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records for the period from March 2021 to the present. 2. After obtaining any additional records, obtain an addendum opinion from a VA examiner other than the April 2021 examiner for the Veteran's hepatitis C. The Veteran's electronic claims file should be made available to the examiner for review in connection with this request. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinion. Following a review of the Veteran's claims file, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's hepatitis C was incurred in or is otherwise related to his active service, to include inoculations received via air gun. For purposes of providing an opinion on this question, the clinician is asked to consider the Veteran's statements that, although he engaged in IV drug use for a short period after service, he did not share needles, to be both competent and credible. As such, in discussing the Veteran's IV drug use, the examiner is asked to clearly address whether IV drug use without sharing of needles is a risk factor for hepatitis C. The examiner should also address the Veteran's reported history of smoking cocaine and using methamphetamines. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Jiggetts 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.