Jet Injectors = Jet Infectors
January 6, 2016
The Board of Veterans Appeals has granted a significant number of jet injector cases. A review of case law from 1992 to 2014 found the Board of Veterans’ Appeals had ruled upon 1,296 cases that cited the jet injector. From these cases 99 were granted, 672 were denied, 468 were remanded back to the VA Regional Office to seek another medical opinion, and 56 cases were granted but needed to be excluded from the rest of the data because either the judicial rendering did not mention the jet injector, the judicial rendering specifically excluded the jet injector, or the veteran’s symptoms of hepatitis C were documented inservice and therefore service-connection was automatically granted and an etiological cause was unneeded. Out of the 99 cases that were granted: 53 cases explicitly rendered that the jet injector was the etiological cause of veterans’ hepatitis C infection; one case explicitly rendered that the jet injector was the etiological cause of the veteran’s hepatitis B infection; 43 cases rendered that veterans’ military exposures, which included jet injector inoculations, were the etiological cause of the veterans’ hepatitis C infection; one case rendered that the veteran’s military exposure which included jet injector inoculations was the etiological cause of the veteran’s hepatitis B infection; and one case found the jet injector caused an adverse condition in a veteran’s upper arm.
Unfortunately, in spite of these wins VA cases do not set any precedents and therefore do not have any probative value in other veteran-claimants’ cases. The VA only has to abide by precedents established in higher courts, such as the United States Court of Appeals and the Supreme Court of the United States. Within the VA each veteran must argue his or her case upon his or her own merits according to his or her own situation. The Board of Veterans’ Appeals explained it like this:
“The facts and findings in prior Board decisions pertain to those veterans’ cases and not to the case at hand. While it appears that excerpts from prior Board decisions may indicate that other Veterans Law Judges accepted medical evidence showing a link between the other veterans’ hepatitis C and their in- service exposure to unsanitary air-jet inoculation guns, any finding in those prior Board decisions is based on evidence associated with the record of those veterans in the other appeals. The Board is not bound by findings found in previous Board decisions. Further, any finding made in a prior Board decision pertains only to the veteran who submitted that appeal. Such a finding is based on the evidence related to that veteran’s medical records and the evidence in that veteran’s claims file. Those decisions do not provide any specific findings or evidence to establish a link between this Veteran’s hepatitis C and any aspect of his period of service” (BVA Case # 1040550).
Although, I do not agree with the non-precedential rule established within VA Law and cite it as a hindrance, I also find that it does not stop veteran-claimants from obtaining justice.
Rather the major concern lays with the VA’s claims process for jet injector cases. Whereupon in numerous instances the medical opinions rendered by VA examiners, VA nurses and VA physicians and the renderings concocted by adjudicators within VA Regional Offices has been nefarious, unscrupulous, unjustifiable, deceitful, illogical, and anything but pro-veteran. More often than not the VA has accused our mighty men and women of valor of egregious conduct as a means to discredit their claims for service-connection. In which the Board of Veterans’ Appeals has at times colluded in these malfeasant actions and at other times was bound by judicial procedure and forced to rule unfavorably.
Here is one of numerous examples whereupon the VA has erroneously discredited a veteran’s claim. In a 2008 Board of Veterans’ Appeals (BVA) case, a VA physician unjustifiably opined that a veteran-claimants hepatitis C could not be related to any of his military risk factors but was related to some unidentified and unrecognized risk factor. This fallacious evaluation was rendered probative and authoritative by the BVA and the veteran’s service-connection claim was denied. Herein the BVA remarked of the physician’s findings:
“The veteran was afforded a third VA examination in May 2006. The examiner stated that while the virus can be transmitted by needle sticks, those incidents are very low. He also asserted that the risk of obtaining HVC [sic.] from injections from an air gun was less than 20 percent. After reviewing the claims file, the examiner noted that the evidence did not show that the veteran injected street drugs, had blood transfusions, received clotting factor, was on kidney dialysis, had liver disease, or had sex or lived with an infected person. Yet, the examiner reported that medical literature shows that up to 20 percent of people with HVC [sic.] do not have identifiable risk factors. Accordingly, he opined that the veteran’s HVC [sic.] was not the result of air gun injections but mostly attributable to an unidentifiable risk factor.” (BVA case # 0817607)
Here the examiner, who was a VA physician, weighed the veterans hepatitis C risk factors—which were accidental needle stick as a healthcare worker in the military and military jet injector inoculations—against statistical findings in medical studies. The VA physician assessed the likelihood that the veteran’s claim matched those studies. In so doing, the VA physician read that the risk of acquiring hepatitis C from a jet injector was less than 20 percent and in 20 percent of hepatitis C cases the risk is unidentifiable. He then attributed, based upon conjecture and not reality, that the cause must be from an unidentifiable risk. The VA physician gave no credence to the risk factors the veteran did experience and failed to recognize that the veteran may have been a part of the less than 20 percent who acquired hepatitis C from jet injector inoculations.
Secondly, the VA has erred by repeatedly ignoring evidence which demonstrated the jet injector posed a risk of disease transmission. Here is an example of a BVA case that denounces the risk of jet injectors:
“The reviewing medical expert stated that there is no published data regarding HCV transmission via air gun inoculation, and that the Center for Disease Control found that air jet inoculation is a safe and effective method for the administration of vaccines. The report reflects that in a cited medical study of chimpanzees infected with hepatitis B, even when air jet injections were done on these animals, the air jet injector did not become contaminated. VHA opinion, received June 2010.” (BVA Case # 1045074)
It is true, the CDC study on chimpanzees did not demonstrate any cross-contamination of HBV. Although this is the only truth in this medical expert’s statement. The CDC does not think the multi-use nozzle jet injectors once widely used within the Armed Forces are safe. In 1994, the CDC reported
“an outbreak of hepatitis B virus (HBV) transmission following use of one type of multiple-use nozzle jet injector in a weight loss clinic and laboratory studies in which blood contamination of jet injectors has been simulated have caused concern that the use of multiple-use nozzle jet injectors may pose a potential hazard of bloodborne-disease transmission to vaccine recipients. This potential risk for disease transmission would exist if the jet injector nozzle became contaminated with blood during an injection and was not properly cleaned and disinfected before subsequent injections” (CDC, 1994).
Currently, jet injector technology has discarded multi-use nozzle jet injectors due to the risks associated with the reusable nozzle and fluid pathways. Second generation jet injectors, referred to as protector cap needle-free injectors (PCNFI) which use a disposable protector cap to cover the reusable nozzle and fluid pathway, have failed to prevent the transference of blood and hepatitis B to the next recipient in clinical testing (Kelly et al., 2008). Third generation jet injectors, known as disposable cartridge jet injectors (DCJI) or dick-jees, have a single-use disposable cartridge assembly that houses the nozzle and fluid pathways to prevent any cross-contamination. DCJI’s are the latest jet injector devices undergoing clinical and field testing. Therefore, the VA medical expert picked one snippet of a study to uphold his claim while failing to disclose a full review of the scientific literature.
Another major concern is that the VA has defended its stance based on the axiom that research shows the majority of veterans acquired hepatitis C from injection drug use and blood transfusions, as is the case in VA Cooperative Study 488. In so doing, the VA has attributed the etiological causes for over 287,000 veterans positive with hepatitis C antibodies based on a study that only assessed 52 veterans with hepatitis C antibodies. Herein the sample size of the study is only two-thousandths of a percent (0.02%) of the population.
Additionally, VA Cooperative Study 488 is grossly outdated. The study sampled veterans in 2001 at which time the Veterans Health Administration (VHA) had roughly 100,000 veterans with hepatitis C in their system. Yet from 2001 to 2014 the number of hepatitis C veterans within VHA’s system rose by over 74,000 people, or rather by 74 percent. There is no guarantee that the risk factors for these additional veterans, who were new patients within the VHA system, are reliably represented in that study.
VA Cooperative Study 488 is a unique study that properly assessed the prevalence of hepatitis C antibodies amongst a random sample of veterans. In this study, veterans were randomly selected and then assessed on whether or not they had hepatitis C antibodies. However, this is the limits to this study. Assessing the etiological causes of only 52 veterans with hepatitis C antibodies, as VA Cooperative Study 488 did, is a weak claim in identifying the risk factors for a larger population. This is evidenced based upon the data, which reported spending more than 48 hours in jail posed a greater risk for hepatitis C than military service (which included combat duty and jet injections). Moreover, the researchers themselves stated it would be difficult to detect a nexus between hepatitis C and jet injectors within their data because the study was population-based.
Briggs and colleagues (2001) also conducted a study to assess the prevalence of and risk factors for hepatitis C within a VA Medical Center. The study found 185 veterans, or rather 17.9 percent of the sample, had hepatitis C. Their study purported,
“History of vaccine in combat or vaccination with an air gun [another name for a jet injector] did not correlate with HCV status (data not shown). However, these questions were added to the questionnaire during the conduct of the study and information was available from only 211 respondents.”
The researchers explicitly disclosed that not all of the sampled veterans received the same questionnaire consisting of the question to evaluate for jet injectors. In fact, the researchers stated only 211 veterans or rather 20.4 percent or rather one-fifth of the sampled population received an updated questionnaire. Yet regardless of this inconsistency the researchers ultimately denounced an association between hepatitis C and jet injector vaccinations within their study. Here, within these two studies, the VA has invalidated the research to obfuscate the jet injector / hepatitis C nexus.
The examples presented herein add to what we already know, the VA is a large bureaucratic administration in desperate need of changes. Please do not misconstrue my stance. I love this country and the principles it was founded upon. Indeed the VA has helped many veterans and has many devoted and talented staff members that make great contributions in the lives of veterans and their families.
However, I find the majority reaction within the VA concerning the hepatitis C epidemic has been inconsistent to the intentions of the administration. The administration needs to be nothing less than 100 percent pro veteran. The administration needs to take the time to unbiasedly learn the etiological causes of hepatitis C veterans.
Veterans and veteran organizations have been relentlessly pushing for these changes within the VA.
- (Briggs et al., 2001) Briggs ME, Baker C, Hall R, Gaziano JM, Gagnon D, Bzowej N, and TL Wright. Prevalence and risk factor for hepatitis C virus infection in an urban Veterans Administration medical center. Hepatology 2001, 34:1200-1205.
- (CDC, 1994) Centers for Disease Control and Prevention. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep 43:(RR-1):7–8, 1994.
- (Dominitz et al., 2005) Dominitz JA, Boyko EJ, Koepsell TD, Heagerty PJ, Maynard C, Sporleder JL, Stenhouse A, Kling MA, Hrushesky W, Zeilman C, Sontag S, Shah N, Ona F, Anand B, Subik M, Imperiale TF, Nakhle S, Ho SB, Bini EJ, Lockhart B, Ahmad J, Sasaki A, van der Linden B, Toro D, Martinez-Souss J, Huilgol V, Eisen S, Young KA. Elevated prevalence of hepatitis C infection in users of United States veterans medical centers. Hepatology. 2005 Jan;41(1):88-96.
- (Kelly et al., 2008) Kelly K, Loskutov A, Zehrung D, Puaa K, LaBarre P, Muller N, Guiqiang W, Ding H, Hu D, Blackwelder WC. Preventing contamination between injections with multi-use nozzle needle-free injectors: a safety trial. Vaccine (2008) 26, 1344-1352.