Citation Nr: 21027421 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-38 327 DATE: May 5, 2021 ORDER Service connection for hepatitis C is denied. VETERAN'S CONTENTIONS The Veteran contends that he incurred hepatitis C during service to include as a result of tattoos; exposures from cuts or immunizations while serving "in country" in Vietnam; numerous small injuries received as a drilling Marine; going on medical relief missions with the military and providing medical care for the local noncombatants; and, exposure to blood from Vietnamese refugees at Camp Pendleton when he would get scratched by barbed wire and assist refugees who had also been scratched or cut by the barbed wire. Furthermore, specific to his claimed National Guard service in Honduras, the Veteran contends exposure from washing patients; transporting wounded personnel to trauma centers; serving in the jungle with special forces medical units; providing support to village medical and dental providers, including pulling teeth, cleaning instruments, and in operating rooms; cleaning and irrigating mortar and gunshot wounds; exposure to blood, including blood from battle; from the water canteen or eating outside in the jungle with flies from outhouses. FINDING OF FACT The preponderance of the evidence indicates that the Veteran's current hepatitis C was not caused by or otherwise related to service; but rather most likely incurred as a result of post-service intravenous drug use. CONCLUSION OF LAW The criteria for service connection for hepatitis C are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1974 to October 1978, with subsequent National Guard service from March 1982 to June 1993. This matter is before the Board following his appeal of a June 2013 rating decision. In July 2018, the Veteran and his wife testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In March 2020, the Board remanded this matter for additional development. Service Connection for Hepatitis C Unfortunately, following a review of the record, the Board finds that service connection for hepatitis C is not warranted, as the evidence weighs against a finding that it was incurred in service. Generally, establishing service connection requires competent evidence of: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). In this case, the evidence clearly shows that the Veteran has been diagnosed with hepatitis C and is currently receiving treatment for the disease and its residuals. See, e.g., June 2018 Private Hospital records (documenting liver transplant for end stage liver disease secondary to hepatitis C). Nevertheless, because the record supports post service incurrence, service connection for hepatitis C must be denied. In this regard, service treatment records (STRs) are silent for a diagnosis of or treatment for hepatitis C, and post-service medical records place its onset in the mid- to late-1990s. See June 2011 SSA Disability Evaluation Report (noting Veteran's report of hepatitis C diagnosis around 1995); October 2002 Initial Private Gastroenterology Consultation (noting an onset of symptoms around 1998). Additionally, the only probative and persuasive opinion evidence of record indicates that the most likely risk factor for the Veteran's hepatitis C is his history of intravenous drug use, which notably occurred post service. Specifically, in a May 2020 opinion, after considering the Veteran's various claimed risk factors as well as other common risk factors among veterans, a VA examiner opined that the Veteran's hepatitis C was more likely than not due to illicit drug use documented in the record. The examiner explained that according to the Center for Disease Control (CDC), the greatest risk factors for hepatitis C are illicit drug use and treatment for hemophilia with products made prior to 1987. In this case, however, there is no evidence that the Veteran is a hemophiliac and, as noted by the examiner, if he was, he likely would not have been accepted into service. The examiner also noted that while other factors do pose a risk, including tattoos, immunizations, multiple sexual partners, or exposure to blood on the battlefield, the "risk is substantial[ly] less than the risk of developing hepatitis C through illicit drug use." Regarding the degree of risk, the examiner explained that high risk activities, with 90 percent prevalence, include illicit injection drug use (past and present, even if only one time), intranasal drug use with shared paraphernalia, and treatment for hemophilia with blood products prior to 1987. Next, intermediate risk activities, with 10 percent prevalence. include blood transfusion before July 1992, organ transplant before 1992, and multiple sexual partners. Low risk activities, with 1-5 percent prevalence, include needle stick exposure and sexual activity with a known hepatitis C infected individual. Rare risk activities with less than 1 percent prevalence include tattooing, acupuncture, and body piercing. Finally, the examiner noted that there are biologically plausible but unproven risk factors, including sharing toothbrushes or razors, and air gun vaccinations. Given the foregoing risk stratification and consideration of the Veteran's history, the examiner found that the greatest risk factor was illicit drug use. Even further, the examiner noted that if an individual has a history of injectable drug use, as well as other or all of the risk factors discussed, the injectable drug use would still be the greatest risk factor and more likely than not the cause of the individual's hepatitis C. Thus, the examiner concluded that it was less likely than not that the Veteran's hepatitis C was causally related to service, and more likely than not due to illicit intravenous drug use. In providing the May 2020 opinion that linked the Veteran's hepatitis C to intravenous drug use, the VA examiner considered the Veteran's medical history, risk factors, and lay contentions; supported the opinion with a detailed rationale; and, cited to specific references in support of the opinion. Thus, the Board finds the opinion to be probative and persuasive. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, the record supports that the Veteran's history of intravenous drug abuse to which his hepatitis is attributed, occurred post service. In this regard, the Veteran's initial report in furtherance of treatment for hepatitis C in October 2002 was that he had a "prior history of intravenous drug abuse in the 1980s," and the Veteran's active service ended in 1978. While the Veteran also had subsequent National Guard service from 1982 to 1993, there is no allegation or evidence that the IV drug use occurred during any qualifying period of active duty for training. Regardless, the Board notes that a grant of service connection is barred when a disability was incurred or aggravated by in-service substance abuse. 38 C.F.R. § 3.301. The Board is cognizant that the record contains two positive medical opinions dated in August 2013 from VA providers. However, one opinion simply stated that it was more likely than not that the Veteran contracted hepatitis C while in the military, with no discussion of the Veteran's service history, medical history, or risk factors, including his post-service risk factors. The second opinion similarly included no discussion of the Veteran's various risk factors and appears to have been based on an inaccurate factual predicate, as it references blood exposure to cuts from barbed wire and other "combat-related wounds," though the Veteran was not engaged in combat. As such, the opinions are inadequate. Finally, while the Veteran may sincerely believe his hepatitis C was incurred in service, he has not demonstrated that he possesses sufficient medical knowledge and training to diagnose himself, provide etiological opinions, and attribute symptoms he experienced to specific disabilities. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In sum, as the only competent and adequate medical opinion of record weighs against the Veteran's claim, the Board finds that the claim of entitlement to service connection for hepatitis C must be denied. S. C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Fagan 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. S. C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Fagan 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.