America’s veterans have been plagued with many health issues since the founding of this country. Hepatitis has long been associated with U.S. military service. Military training and combat present many opportunities for transmission of viral hepatitis through blood-to-blood contact. Field bleeding, surgery, transfusions, and exposure to blood by military medics and surgeons all constitute high risks. During World War I, thousands of American GI’s were stricken with hepatitis A. To this day, service men and women still become ill with hepatitis A, B, and C (formerly known as non-A, non-B hepatitis).

Since the identification of the hepatitis C virus (HCV) in 1989, physicians and Veterans Administration (VA) officials have seen large numbers of infection among veterans. Veterans appear to have unusually high rates of hepatitis C. While the prevalence of hepatitis C in the general population is approximately 1.8%, various studies in VA facilities have shown hepatitis C virus (HCV) prevalence rates between 10-20% among veterans.¹

Veterans of foreign combat appear to be at the highest risk for infectious hepatitis. All major engagements of the last 60 years, World War II, the Korean War, and the Vietnam War, were associated with high rates of infectious hepatitis. Viral hepatitis was viewed as a single disease in the early years, and most treatment and documentation of it were for the acute forms of the disease.

Veterans and Hepatitis C Timeline

Veterans' Hepatitis C Survey

Bruskin-Goldring Research conducted a national survey commissioned by VATA of 504 veterans in 1999. Ages of those surveyed ranged from 40-60, with a mean age of 49. Following are some of the highlights from that survey.

74.8% were “not very” or “not at all” concerned about their risk for HCV
60.1% had not been tested for HCV
58.3% were “not very” or “not at all” likely to be tested for HCV
67.5% were “not very” or “not at all” familiar with the disease
63.3% recognized flu-like symptoms, and 57.7% recognized yellow skin as possible symptoms of liver disease
1.6% knew that hepatitis C often has no symptoms
9% initially acknowledged they might be at risk for hepatitis C
45% acknowledged they might be at risk after being informed of risk factors
65.1% stated their greatest fear about HCV is the possibility of infecting a loved one
62.9% stated their next greatest fear was the possibility of having a serious illness or dying from a serious illness

These findings clearly indicate there is a need for HCV education. Veterans must be informed of their risk for hepatitis C, and about the seriousness of the disease.

The Incidence of Hepatitis C Among America's Military Veterans

Veterans’ advocates have grown increasingly concerned in recent years about the incidence of hepatitis C among military veterans. Several studies have suggested veterans may be at higher risk than the general public. According to testimony given before the U.S. Senate Committee on Appropriations, Subcommittee on Veterans’ Affairs, 69,000 veterans in VA facilities have tested HCV positive since 1999.⁵ Studies at the VA Medical Centers (VAMC) in Washington D.C. and San Francisco found the prevalence of HCV positive inpatients was 20% and 10%, respectively.¹ One of these studies also found 52% of patients requiring liver transplant were HCV positive.¹

In 1998, a national tracking system analyzed the findings from 95,000 hepatitis C screening tests performed in the VA system.⁴ Of those who tested positive:

64% were Vietnam veterans
18.5% were post-Vietnam veterans
4.5% were Korean era veterans
4.2% were post-Korean era veterans, and
9.1% were Veterans from other periods of service.

Veterans of the Vietnam War: The Largest Military Population Most At Risk

Of the 8.1 million surviving veterans of the Vietnam War, 3.2 million had active duty in Asia between 1964 and 1973.⁶ It is conservatively estimated that 10% of these Asian theater veterans are now infected with HCV.¹

Modes of Transmission of HCV in the Asian Theater of the Vietnam War

There are a number of HCV risk factors for veterans who were in Asia during the Vietnam War, many related to the high prevalence of HCV in southeast Asian countries. It is estimated that 5-8% of the Vietnamese population is infected with HCV.⁷

Transfusions

Transfusion of blood or blood products before 1992 is a known risk factor for HCV infection. Prior to 1992, there were no accurate HCV screening tests to ensure the safety of the blood supply with respect to HCV.³ Three hundred thousand Americans were wounded and 153,329 were hospitalized during the Vietnam War. Between March 1967 and June 1969, 364,900 Americans in Vietnam received blood transfusions.² It is estimated that a minimum of 10% of those transfused received HCV infected blood.⁸

Medical Contact

Surgeons, nurses, medics, helicopter crews, and others involved in the evacuation and treatment of the wounded from Vietnam were also placed at risk for HCV infection because of their blood exposure. An estimated 41.1% of all soldiers deployed to Vietnam, approximately 2.1 million veterans, were involved in combat. Many soldiers assisted the more than 300,000 wounded. Medical personnel on hospital ships were also placed at risk via their exposure to wounded soldiers from the Vietnam theater.⁹

Tattoos

Unclean needles that pierce the skin can transmit HCV. While transmission of HCV by tattooing has not been fully documented in the U.S., it has been documented elsewhere.¹⁰ An estimated 34% of active-duty military personnel have tattoos (personal communication, Capt. John Mateczun, Principal Director, Clinical Affairs, Office of Health Affairs, Department of Defense). Many of these tattoos were and continue to be acquired in countries where sanitation is often substandard.

Sexual Contact

Although sexual transmission of HCV occurs, it is believed to be relatively uncommon. Nevertheless, a portion of those infected with HCV during the Vietnam War were probably infected through sexual contact with Vietnamese nationals.

Recreational Drug Use

Sharing drug paraphernalia is currently the most common cause of newly acquired HCV infections. This was also a risk factor during the Vietnam War. A study from the Centers for Disease Control and Prevention on the health status of Vietnam veterans found 3% had used “hard drugs,” including amphetamines, barbiturates, cocaine, heroin, psychedelics, phencyclidine and methaqualone.¹¹

VA Monitoring of HCV-Infected Veterans

The Department of Veterans Affairs has noted a decided increase in the number of HCV cases diagnosed over the past several years. There were 6,600 HCV cases reported in the VA system in 1991. By 1994, this number had increased to 18,854. Over the next four years, the annual number of newly identified cases increased steadily to 20,203 in 1995, 21,424 in 1996, 24,850 in 1997, and 29,799 in 1998. Since March 1999, over 69,000 additional cases have been identified. VA officials expect this number to continue to increase substantially.¹²

Testing of veterans outside the VA medical system has confirmed the high HCV prevalence in this population. A 1998 screening program that tested 200 apparently healthy leaders of the Vietnam Veterans of America found 9% of those tested were infected with HCV. ¹³ A more recent screening at a Vietnam Veterans’ stand down found 36% of those screened tested positive for HCV. Although these numbers are preliminary, they all point to the fact that veterans have consistently high rates of HCV infection of at least 10%, more than five times the prevalence rate in the general population.

In June 1998, the VA issued new HCV screening guidelines for veterans entering VA facilities who have one or more of ten specified risk factors. The VA has also established two Centers of Excellence located at the VA medical centers in Miami and San Francisco. These centers coordinate treatment and research efforts, and develop educational programs for patients and their families. Health care providers who specialize in HCV and patient counselors are also located at these centers. These centers established the current guidelines for VA clinicians who treat patients with hepatitis C.

The VA expects the new screening guidelines will dramatically increase the number of VA patients identified with hepatitis C. The demand for HCV related services is expected to rise proportionately. The screening guidelines indicate that any veteran who requests HCV testing should be tested regardless of his or her risk factors.

In December 1999, the VA adopted treatment guidelines for HCV infection. The guidelines recommend that eligible veterans be given the very best medical care, including the most recently approved treatment. Of course, only veterans who are income eligible or service connected for HCV can receive treatment through a VA medical center. Despite the treatment guidelines, veterans report problems obtaining care due to constraints put on HCV health care at the Veterans Integrated Service Network (VISN) level.

The one fact on which we can all probably agree is that hepatitis C among military veterans is an overwhelming problem for the Veterans Administration.