Nov. 11, 1999 (Dallas) -- Experts at the 50th Annual Meeting of American Association for Liver Disease reported that more and more veterans -- particularly Vietnam-era veterans -- will die as a result of infection with hepatitis C.
Currently about 3.5 million veterans receive their medical care at Veterans Affairs (VA) Medical Centers. Megan Briggs, MPH, says a screening study of veterans treated at an outpatient clinic at the San Francisco VA Medical Center suggests that as many as 18% of veterans are infected with hepatitis C, a virus that lingers undetected for decades but may suddenly flare up. When the virus becomes active it attacks the liver, causing scarring and eventually cirrhosis. Patients with cirrhosis due to hepatitis C are also at an increased risk of developing liver cancer. Cirrhosis and liver cancer often lead to the need for a liver transplant.
In recent years, the VA has become aware of a growing number of hepatitis C cases among both its outpatient population and hospitalized veterans, says Theresa L. Wright, MD, chief of gastroenterology at the VA Medical Center in San Francisco. Wright and Briggs co-authored a study based on screening of veterans receiving outpatient care.
Wright says that among the risk factors associated with hepatitis C infection, "IV drug abuse just overwhelmed all other factors." That's significant because the highest prevalence was found among "patients in their late 40's and early 50's -- the veterans of the Vietnam era." She says that, "it isn't simply a matter of having served in Vietnam but rather a timing thing: Vietnam coincided with the explosion of IV drug abuse in the U.S." Thus, it is the timing of service that links these veterans to the disease.
The link between Vietnam-era veterans and hepatitis C is compelling, according to a fact sheet from Samuel B. Ho, MD, assistant professor of medicine at the VA Medical Center, and University of Minnesota, Minneapolis. The sheet cites a VA tracking study that analyzed 95,000 hepatitis C tests from 173 VA centers and 600 VA associated clinics. That study found that Vietnam-era veterans account for about 64% of positive hepatitis C tests, he tells WebMD.
Ho says that the Vietnam-era veteran who receives treatment at the VA carries a laundry list of risk factors for hepatitis C. "Veterans of this age who get their medical care at the VA either have service-connected injuries or are here because they have chronic problems such as drug and alcohol abuse or psychiatric diagnoses that prevent them from working, and thus they qualify for care." Ho says any service-connected injury may have "exposed the person to contaminated blood," and addictions "are strongly associated with IV drug use."
Another risk factor identified by Briggs and Wright is "needle-stick during combat medical service," says Briggs. She says needle-stick and other medical treatment blood exposure may have been more common during Vietnam "because they operated in situations where they were just surrounded by blood." Wright says that if this risk factor can be confirmed in larger studies, "it may become a question of liability for the VA. If the hepatitis C is a result of needle-stick while serving as part of a medical unit, I think there may be some liability for treatment."
Questions such as that have led the VA to consider a national study to determine the true incidence of hepatitis C in the VA population. "That's why we are conducting this study in San Francisco, and we will do another pilot in Seattle," says Wright. She says the VA will use those pilots to design a national study.
While awaiting a national prevalence study, Ho has developed a screening and treatment model for use in regional VA centers in Minnesota. He has initiated hepatitis C screening as part of standard outpatient care and has developed education and treatment guidelines for veterans who test positive.
But even though the VA has approved use of the latest therapy for hepatitis C -- a combination of two powerful drugs, interferon and ribavirin -- many of the patients treated at the VA are not good candidates for treatment. The treatment, says Ho, is usually not recommended for patients who have alcohol or drug abuse problems or who have a diagnosis of a psychiatric illness. One of the side effects of interferon treatment is depression, he says.
Wright agrees that the outpatients treated by the VA are not the best candidates for therapy, but "we know that we get a 40-50% response with combination therapy. I think that somewhere in that 350,000 that we think are hepatitis C positive there must be enough people who will achieve that response that it makes it worthwhile to find them."