Citation Nr: 21015694 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 13-33 095 DATE: March 18, 2021 ORDER Entitlement to service connection for hepatitis C with cirrhosis of the liver is denied. FINDING OF FACT The preponderance of the evidence is against finding that hepatitis C with cirrhosis of the liver 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 with cirrhosis of the liver have not been 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 has active service from January 1975 to June 1975 as well as periods of training with the Marine Corps Reserves. This case is before the Board of Veterans’ Appeals (Board) from an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned Veterans’ Law Judge at an August 2015 hearing. In October 2018, the Board remanded the claim to the RO for additional development. In August 2020, the Board found there had not been substantial compliance with the prior remand directives and remanded the claim again. An addendum opinion was obtained, and the Board finds there has been substantial compliance with the remand directives in accordance with Stegall v. West, 11 Vet. App. 268, 271 (1998), and the Board may proceed with appellate review. Service connection for Hepatitis C with cirrhosis of the liver. The Veteran contends that he contracted hepatitis C through the shots he received in boot camp with the air jets or alternatively, through the tattoo he obtained while he was on active duty during two weeks service (8/09/2015 Hearing Transcript, pgs. 3 and 7). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this case, the Veteran has a current diagnosis of Hepatitis C (6/04/2020 CAPRI, pg. 4) and evidence shows treatment for a tattoo during ACDUTRA (6/21/2010 STR - Medical – Photocopy, pg. 2). Additionally, the Board concedes that he was administered vaccines upon entry to service. Nevertheless, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of hepatitis C began during service or is otherwise related to an in-service injury, event, or disease. Turning to the medical evidence of record, in favor of the Veteran’s claim is a September 2015 letter from a private physician finding it more than likely that the Veteran acquired Hepatitis C as a result of a tattoo in 1979 (10/14/2015 Medical Treatment Record - Non-Government Facility). An October 2015 medical record note stated the Veteran was seeking a letter that states that his Hepatitis C is due to a tattoo during his military duty. The writer explained that a letter was written that his tattoo could be the cause of Hepatitis C, also stating there is no way to determine the cause for sure (4/18/2016Medical Treatment Record - Non-Government Facility, pg. 66). Weighing against the Veteran’s claim is a November 2013 letter from a private practitioner concluding that the Veteran’s hepatitis C is not at least as likely as not connected to his duty while in the military. The practitioner opined the Veteran’s risk factors for Hepatitis C included a tattoo and multiple sexual partners. The practitioner added that the Veteran’s cirrhosis was confirmed in 2009 and it takes 30 to 40 years from the time a person contracts Hepatitis C to develop cirrhosis (12/19/2013 Medical Treatment Record - Non-Government Facility). A copy of this letter without the 30 to 40-year estimate is also of record (4/11/2016 Medical Treatment Record - Non-Government Facility, pg. 55). The Veteran was afforded a VA examination in July 2017. The examiner reviewed the service treatment records, revealing risk factors of multiple sexual partners and tattoo. The examiner stated an opinion with regard to etiology of the Veteran’s hepatitis could not be provided without speculation (7/14/2017 C&P Exam, pg. 4). A July 2019 addendum opinion was obtained. The examiner opined that the condition claimed is less likely than not (less than 50 percent probability) due to service including the tattoo or vaccination. The examiner explained that multiple risk factors for Hepatitis C were noted and literature concerning air gun vaccinations is not specific regarding cause and effect. In an October 2019 addendum, the examiner provided the opinion that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that no evidence of blood transfusions or exposure to bloody objects in service was noted, which are the highest concerns for exposure based on VA medical research. The examiner noted that the tattoo was not during active duty. The examiner adopted the pervious explanation regarding air gun vaccinations. With regard to history of multiple sexual partners, without the hepatitis C status of the partners, an exact odds ration cannot be obtained (10/07/2019 C&P Exam, pg. 1). An October 2020 addendum opinion cited to research with regard to contracting Hepatitis from a tattoo, citing that it remains unknown whether the transmission risk is from tattooing itself for from another associated risk. The examiner addressed the air gun inoculation method, finding no peer reviewed studies noting a cause and effect relationship between the instruments delivering the vaccine and developing hepatitis C. With regard to cirrhosis requiring a hepatitis C infection for 30 to 40 years, the examiner cited to other research noting that the rate is 5 to 30 percent over a 20 to 30-year period although slower and faster rates of progression have been found (10/15/2020 C&P Exam). In weighing the evidence, the Board notes the Veteran was not diagnosed with Hepatitis C until decades after his separation from service. While he is competent to report having experienced symptoms of dark urine and fatigue since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of Hepatitis C. The Veteran believes his hepatitis C, evidenced as early as 1985 by dark urine, and significant bouts with fatigue as early as 2005 (8/09/2015 Hearing Transcript, pgs. 6-7), is related to an in-service injury, event, or disease, specifically vaccines administered with an air gun or a tattoo obtained during service. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, requiring knowledge of pathology. It is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the medical evidence of record. In weighing the medical evidence of record, the Board notes the September 2015 private opinion includes no rationale for the positive nexus provided. There is no rationale that the Board may consider against other opinions of record. Because the opinion lacks sufficient rationale, the opinion is assigned no probative weight. (Continued on the next page)   Taken together, the VA opinions from July 2017, July 2019, October 2019, and October 2020 weigh against the Veteran’s claim that his Hepatitis C is related to an in-service injury, event, or disease, specifically air gun vaccination or a tattoo. Collectively, they are grounded in the facts of the case, the Veteran’s medical history and are supported by thorough rationale and references to medical literature. The examiners’ combined opinion is highly probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In light of the foregoing, the Board finds the preponderance of the evidence is against finding that the Veteran’s hepatitis C with cirrhosis of the liver began during active service or is otherwise related to an in-service injury or disease to include vaccinations administered with an air gun or a tattoo. Accordingly, the Veteran’s claim is denied. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. A. Myers 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.