Union Calendar No. 461

105th Congress, 2d Session
House Report 105 820
HEPATITIS C: SILENT EPIDEMIC, MUTE PUBLIC HEALTH RESPONSE
SEVENTH REPORT by the COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

Washington, DC, October 15, 1998.  
 Hon.  Newt Gingrich,
Speaker of the House of Representatives,
Washington, DC.                                                        

Dear Mr. Speaker : By direction of the Committee on Government  Reform and Oversight, I submit herewith the committee's seventh report  to the 105th Congress. The committee's report is based on a study conducted by its Subcommittee on Human Resources.
                      
Dan Burton, Chairman.           

VA researcher Dr. Gary Roselle published the first large study of HCV  infection in VA patients in November 1997. In a mandatory survey of VA  health care facilities, the number of HCV antibody positive patients increased as follows:                                                  

            6,612 in 1991                                              

            8,365 in 1992                                              

            14,097 in 1993                                             

            18,854 in 1994 (the last year with published data).        


    He concluded, ``This represents an increase of more than 285% during 
  the 4 year period.''\31\                                               
                                                                          

   \31\Gary A. Roselle, Linda H. Danko, Charles L. Mendenhall ``A Four-Year    Review of Patients with Hepatitis C Antibody in Department of Veterans  Affairs Facilities,'' Military Medicine, 162, 711 714, 1997.    

 Since most veterans are not treated in VA medical facilities, the  actual incidence of HCV infected veterans is undoubtedly much greater.  VA has not conducted widespread surveillance to ascertain the number of
infected veterans.                                                     

There is much speculation that Vietnam era veterans, now in their  40's and 50's, are at much greater risk of HCV infection due to heavy      transfusion activity during the Vietnam war. Dr. Roselle concluded, ``Of   particular interest to the VHA [Veterans Health Administration] is the     possible relationship of HCV disease with service in Southeast Asia        during the Vietnam era. Although HCV strain differences may not be         useful for determining specific sources of infection, amplification of 
   this blood-borne pathogen (e.g. transfusions) among the troops is a        conceivable explanation for a number of HCV infected persons identified    in this study. Further epidemiologic data will be required before this  issue and that of service connection can be resolved.''\32\            
                                                                          

   \32\Ibid.                                                              

Former Surgeon General C. Everett Koop is among physicians who have     called for an HCV screening program for all U.S. military personnel. In    May 1997, Senator Richard Shelby (R AL) asked the Pentagon to look         further into the possibility that immune globulins may have spread HCV.    The Pentagon did not agree to study the issue and Senator Shelby       inserted the following report language in the 1998 Department of Defense

   Appropriations bill: ``The Department of Defense shall determine rates of hepatitis C infection among personnel who served in deployments      overseas or who received blood plasma products from individuals infected   with hepatitis C and provide counseling and access to treatment for   personnel as needed.''\33\                                             
                                                                          

   \33\Senate Report 105 45, Committee on Appropriations, Department of    Defense Appropriation Bill, 1998.    

Also, DOD does not have an accurate estimate of the prevalence of HCV in the military. As a result, veterans cannot
establish a service connection for HCV infection contracted in military service and are therefore not entitled to treatment for HCV or related liver disease in VA facilities.

DOD stated in a fact sheet produced in July 1997 that, ``HCV infections among military service members mirror those observed in the United States civilian population . . .'' New recruits, like other young people, have lower than average HCV infection rates. DOD policy is to screen or treat when clinically indicated, despite the fact that Hepatitis C rarely manifests acute symptoms.
Military service does involve exposure to some known risk factors for transmission of HCV such as: contact with HCV infected blood in  training, in combat and through transfusions; medical and surgical care; service in regions with high rates of HCV infection such as Asia and  North Africa; tattoos and IV and non-IV drug use.

DOD cites studies in which military members did not have increased incidence of HCV infection. Those studies found no evidence that foreign travel or other geographic risk factors placed military members at greater rates of infection than non-military personnel.
Veterans who are seeking now to establish a service connection for their HCV and liver disease are being rejected by the Board of Veterans Appeals because they cannot show competent evidence of a nexus between any disease in service and their current HCV. Of 1,599 chronic hepatitis cases before the panel between 1994 and 1996, only 37 were approved, according to recent analysis of case data collected by the Board and made publicly available on CD ROM. The Board's decisions were based largely on the conclusion that episodes of acute hepatitis during service were ``healed'' prior to discharged, a conclusion that could be
refuted with a blood test at the time of discharge.
 

STATEMENT OF TERESA L. WRIGHT, MD CHIEF, GASTROENTEROLOGY SECTION, SAN FRANCISCO VETERANS ADMINISTRATION MEDICAL CENTER BEFORE THE HOUSE VETERANS' AFFAIRS COMMITTEE SUBCOMMITTEE ON BENEFITS July 16, 1998 From our own experience at the San Francisco VA Medical Center, HCV disease is a common problem. In those who were tested as part of a city-wide needle-stick study, 10 per cent of hospitalized veterans were seropositive for HCV. This is substantially lower however than the experience at San Francisco General hospital where the seroprevalence is 30 per cent. Of 195 seropositive veterans attending the San Francisco VA liver clinic, 78% are between the ages of 40 and 59 years. In a limited survey of 48 seropositive veterans, 24% had served in Vietnam, 2% had served in Korea, 4% had served in World War II, but more than 60% had never been in combat. ...These results imply that HCV infection is being acquired in Veterans from U.S. rather than European or Asian sources. Our study was not designed to assess the prevalence of HCV infection in veterans as a whole nor in subpopulations of veterans such as those who served in Vietnam. These questions are being addressed in a study which is just getting underway at our VA and which is funded for the coming five years. Five years later VA Study 488- Elevated Prevalence of Hepatitis C Infection in Users of  United States Veterans Medical Centers-In summary, we estimate that 5.4% of VA users are HCV-seropositive, exceeding the estimate from the general population by more than 2-fold. Although Vietnam veterans had the highest prevalence (11%) in our sample, military-related exposures were not found to be significant risk factors. That this estimate differs considerably from some prior estimates used to determine health policy underscores the need for methodologically sound epidemiological research to guide health policy decision makers. Given the relatively high prevalence of HCV, the Department of Veterans Affairs should continue to support prevention, screening, counseling, and treatment efforts to reduce the frequency of HCV complications.

 

H.R.1020
Title: To amend title 38, United States Code, to establish a presumption of service connection for the occurrence of hepatitis C in certain veterans.
Sponsor: Rep Snyder, Vic [AR-2] (introduced 3/4/1999)      Cosponsors (120)
Latest Major Action: 4/13/2000 House committee/subcommittee actions. Status: Subcommittee Hearings Held.

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ALL ACTIONS:

3/4/1999:

Referred to the House Committee on Veterans' Affairs.

4/21/1999:

Referred to the Subcommittee on Benefits.

4/13/2000:

Subcommittee Hearings Held.

Veterans' Hepatitis C Benefits Act of 1999 (Introduced in House)
 

HR 1020 IH

 

106th CONGRESS

 

1st Session

H. R. 1020

To amend title 38, United States Code, to establish a presumption of service connection for the occurrence of hepatitis C in certain veterans.

IN THE HOUSE OF REPRESENTATIVES

 

 

March 4, 1999

 

Mr. SNYDER (for himself, Mr. EVANS, Mr. FILNER, Ms. CARSON, Mr. MINGE, Ms. BROWN of Florida, Mr. ABERCROMBIE, Mr. SHOWS, Mr. DICKEY, Mr. SMITH of New Jersey, Mrs. MCCARTHY of New York, and Mr. WELDON of Florida) introduced the following bill; which was referred to the Committee on Veterans' Affairs

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A BILL

To amend title 38, United States Code, to establish a presumption of service connection for the occurrence of hepatitis C in certain veterans.

 

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

 

SECTION 1. SHORT TITLE.

 

This Act may be cited as the `Veterans' Hepatitis C Benefits Act of 1999'.

 

SEC. 2. PRESUMPTION OF SERVICE CONNECTION FOR HEPATITIS C FOR VETERANS.

 

(a) IN GENERAL- Subchapter II of chapter 11 of title 38, United States Code, is amended by adding at the end the following new section:

 

`Sec. 1119. Presumption of service connection for hepatitis C

 

`For purposes of section 1110 of this title, and subject to section 1113 of this title, hepatitis C becoming manifest in a veteran shall be considered to have been incurred in or aggravated by active military, naval, or air service, notwithstanding that there is no record of evidence of such illness during the period of such service if it is shown that during such service the veteran experienced one or more of the following:

 

`(1) Transfusion of blood or blood products before December 31, 1992.

 

`(2) Blood exposure on or through skin or mucous membrane.

 

`(3) Hemodialysis.

 

`(4) Tattoo or body piercing or acupuncture.

 

`(5) Unexplained liver disease.

 

`(6) Unexplained abnormal liver function tests.

 

`(7) Working in a health care occupation.'.

 

(b) CLERICAL AMENDMENT- The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 1118 the following new item:

 

`1119. Presumption of service connection for hepatitis C.'.