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VA Hepatitis C Prevalence Study Results Summary and VA Hepatitis C Program Actions
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This is a report issued by the VA. The actions listed below that the VA says it takes such as testing & screening programs at the VA is reported by the FDA not by me.
March 11, 2004
National Hepatitis C Program Office
Public Health Strategic Health Care Group
Veterans Health Administration
Department of Veterans Affairs
The study below was presented at the VA Health Services Research and Development Meeting in Washington, DC, March 10, 2004. Study results are under review but are not yet published in a scientific journal.
Findings
VA Cooperative Study 488 was a large study designed to look at prevalence (rate) of and risk factors for hepatitis C in veterans enrolled in Veterans Health Administration (VHA) health care. VA researchers gathered data (via questionnaires and blood testing) on 1,288 veterans in 20 randomly selected VA medical centers, the largest, cross-VA study on hepatitis C ever conducted. VA Cooperative Study 488 found a rate of hepatitis C infection in veterans who use VHA health care to be 5.4%.
This is higher than the overall U.S. rate (1.8%) and the rate in U.S. residents who have ever served in the military (1.7%) found by a large-scale national study done by the Centers for Disease Control and Prevention.
This is lower than previous VA studies (ranging from 6.6%-35%) that were either smaller or non-representative of veterans who use VA health care.
The highest rates of hepatitis C were found among veterans who used injection drugs, those who served in the Vietnam era, those who had ever been in jail for more than 48 hours, and those who had tattoos.
No association was found in this study for other possible risk factors such as combat duty, exposure to blood in combat, being wounded in combat or vaccinations given by use of airgun injectors.
VHA Actions
For the past several years, VA has had a proactive program of screening and testing for hepatitis C in veterans who use VHA health care and has already identified approximately 250,000 veterans with evidence of hepatitis C exposure.
Other VHA data show that the large majority of veterans who use VHA health care who are at high risk have already been screened or tested for hepatitis C.
VHA will use the results of this study to focus hepatitis C screening and testing activities on veterans who use VA health care who are at highest risk of exposure.
Details
Prevalence findings: A research study (VA Cooperative Study 488) presented at the VHA Health Services Research and Development meeting in Washington, DC, on March 10, 2004, found that the best point estimate of the prevalence of hepatitis C infection among veterans using VHA health care facilities is 5.4% and, with 95% certainty, that the true prevalence lies between 3.3 and 7.5%. This is lower than in some previously published studies of selected groups of veterans in VHA care, but higher than the prevalence in the overall population of U.S. residents with military service, estimated by the Centers for Disease Control and Prevention to be 1.7% (1) . VA Cooperative Study 488 found highest rates of infection among those who served during the Vietnam era (11.5%, with a 95% confidence interval of 6.5 to 16.1 per cent) compared to other eras. After the study controlled for the known risk factor of intravenous drug use, the only other factors found significantly associated with hepatitis C infection were the presence of tattoos and any history of incarceration for more than 48 hours. The high prevalence of these risk factors among veterans who use VA for health care is likely to account for the hepatitis C prevalence that was shown in this study.
VA National Hepatitis C Program efforts: VA´s efforts to identify all users of its health care services who are infected with hepatitis C have been highly effective and unique within the world of large health care systems. With a policy of universal risk factor screening and testing of all those with positive risk screens, VA has identified over 250,000 veterans with hepatitis C in care since 1996. Nearly 190,000 of these veterans received care in FY2003. Results of systematic reviews of patient charts indicate that approximately 95% of veterans enrolled in primary care or mental health clinics have been screened for hepatitis C risk factors, and that 85% of these have been tested or diagnosed. However, VA Cooperative Study 488 and other, smaller reviews within VA facilities suggest that there are veterans who have risk factors for hepatitis C and have not yet been tested. It is thought the undiagnosed cases of hepatitis C exist largely among veterans whose care in VA is sporadic or episodic. Based on these findings, the VA intends to broaden its case finding efforts particularly among infrequent users of its health care services.
Military factors: VA Cooperative Study 488 also investigated possible links between hepatitis C infection and military-related factors. After accounting for the effects of known risk factors, no link was found between hepatitis C and history of combat duty, exposure to blood in combat, or being wounded in combat (as reported by the study participants). This is consistent with the finding in other studies that hepatitis C risk is not increased among the large number of Americans with history of military service.
This study also examined the possible link between hepatitis C infection and the receipt of inoculations during military service given by high-speed jet injectors (also known as airguns). After accounting for the effects of known risk factors, no such association was found. It is possible that if transmission of hepatitis C did occur via the use of jet injectors, it happened in isolated circumstances, or on a small scale. Such events would be difficult to detect in a population-based prevalence study like VA Cooperative Study 488. To date, the use of jet injectors for inoculation has been linked with certainty (rarely) only to transmission of hepatitis B; their use has never been documented to transmit hepatitis C.
Summary: VA Cooperative Study 488 has increased our understanding of the magnitude of the burden of hepatitis C among veterans who use VHA for health care. The study confirmed that Vietnam-era veterans are the age group most frequently infected and that, after controlling for the known risk factor of injection drug use, a history of incarceration for more than 48 hours and a history of tattoos were also significant risk factors. The study did not demonstrate an association with past military factors including jet injector inoculations, but did not have the capacity to link jet injector use with hepatitis C infection that might have occurred in isolated, infrequent circumstances. Veterans who feel their specific history makes them eligible for service-connected compensation for their hepatitis C infection will be evaluated on an individual basis by the Veterans Benefits Administration (http://www.vba.va.gov).
Bibliography on Hepatitis C and Veterans
The following is a brief annotated bibliography of key journal articles pertaining to rates of hepatitis C infection among veterans and veterans who use VA health care services.
1. Alter MJ, et al. The prevalence of hepatitis C virus infection in the United States, 1988-1994. N Engl Jour Med 1999;341: 556-62.
This article reports the finding of the National Health and Nutrition Survey (NHANES) conducted by the Centers for Disease Control and Prevention. In this study, hepatitis C prevalence was 1.7% among Americans with any history of military service and 2.2% among those without military service history. The overall rate in the US population was estimated to be 1.8%
2. Cheung R. Epidemiology of hepatitis C infection in American veterans. American Journal of Gastroenterology 2000; 95:740.
This study reported that of 8,558 veterans seen in the Palo Alto VA Health Care System who had hepatitis C tests ordered by their medical care providers, 2,985 (35%) were infected. 60 percent of those infected were between the ages of 41 and 50 at the time of testing and 81% had a history of injection drug use.
3. Briggs ME, et al. Prevalence and risk factors for hepatitis C virus infection at an urban Veterans Administration medical center. Hepatology 2001. 34: 1200-5.
This study examined hepatitis C infection rates among a random sample of veterans who were waiting to have blood drawn for other purposes in a VA facility. 17 percent of those who agreed to participate in this study at the San Francisco VA Medical Center were infected with hepatitis C.
4. Roselle GA, et al. National Hepatitis C Surveillance day in the Veterans Health Administration of the Department of Veterans Affairs. Military Medicine 2002. 167: 756-9.
On a single day in 1999, all veteran inpatients and outpatients who were having blood drawn in VA facilities were asked to consent to having their blood also tested for hepatitis C. 6.6% of those who agreed to be tested were infected with hepatitis C.
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