By Mike Richman, VA Research Communications

To what extent does military exposure, including time in combat, put someone at risk for acquiring hepatitis B?

The virus causes a liver infection that, if not treated properly, can lead to serious health consequences, such as cirrhosis—a deterioration of the liver—liver cancer, or even death.

Potential military contributors to hepatitis B have not been thoroughly explored, especially those related to combat exposure, blood transfusions, or travel to regions where the hepatitis B virus occurs at a high rate.

Now, a new study finds Veteran prevalence of hepatitis B to be greatest among those with traditional risk factors, such as drug-use or high-risk sexual practices, but also suggests that combat exposure can be a risk factor on its own. Hepatitis B can be acquired, for example, by being wounded or making contact with infected blood when a fellow service member is wounded.

Navy Veteran Natale Stella (left), seen here with Dr. Lauren Beste, has lived with hepatitis B for two decades but has never experienced any symptoms. (Photo by Chris Pacheco)
Navy Veteran Natale Stella (left), seen here with Dr. Lauren Beste, has lived with hepatitis B for two decades but has never experienced any symptoms. (Photo by Chris Pacheco)

Dr. Lauren Beste, an assistant professor at the University of Washington, internist at the VA Puget Sound Health Care System and a senior official in VA’s HIV, Hepatitis, and Related Conditions Program Office, led the research. She believes the study, which appeared online in the journal Clinical Gastroenterology and Hepatology in August 2019, is the first to gauge the prevalence of hepatitis B in relation to combat.

Her study included 1,146 Veterans who received VA care from 1998 to 2000. Estimates of hepatitis B among VA users before the 21st century were based on laboratory results and administrative data from the less than 30% of patients tested for the virus in the course of standard medical care.

Beste and her team found that evidence of hep B exposure was highest among Veterans with traditional risk factors, such as drug use or high-risk sexual practices. Of these people, 60% reported a history of combat exposure. After adjustment for demographic and traditional risk factors, the researchers determined that service in a combat zone and being wounded in combat were independently associated with exposure to hepatitis B.

The study team concluded that more research is needed to determine whether Veterans who were in combat prior to the era of universal vaccination should be screened for exposure to hepatitis B. The military began vaccinating all service members for the disease after 2000. Vets who have served in the 21st century are presumed to be vaccinated and thus protected from the virus.

“The hepatitis B virus has effective treatments and can be identified with a simple blood test, but military service is not one of the risk factors that is traditionally used to prompt screening,” says Beste.

“There are many important reasons to study whether military exposures are linked to hepatitis B. One is to make sure we offer screening to Veterans who could be at risk. Another is to give Veterans a chance to apply for VA compensation if their hepatitis B is related to military service.”

Hepatitis B not a curable disease

It’s important to note that the study does not show cause and effect, only an association between combat and hepatitis B. The researchers can’t prove definitively that any case of hep B came about because of a combat wound or contact with infected blood in a combat setting.

"This kind of study cannot prove a causal relationship," Beste says. "We can only prove that combat and hepatitis B exposure are somehow linked. In lay terms, somebody with blood evidence of hepatitis B exposure is saying, `No, I didn't inject drugs. No, I didn't engage in risky sex. No, I didn't have an occupational needlestick injury. But I was in a combat situation.'" 

"The association between combat and hepatitis B relies on the accuracy of responses from people to the questions about risk factors. That said, combat seems to be an independent risk factor based on the data we have available. Furthermore, as a physician, my job is to identify who needs to be screened for hepatitis B, regardless of the way the hepatitis B exposure may have occurred. From a practical standpoint, Veterans with combat history do appear to have an increased risk for hepatitis B exposure."

The hepatitis B virus is transmitted when people come in contact with the blood or bodily fluids of someone else who has the virus. This most often happens through sexual contact or the sharing of needles, syringes, or other drug-injection equipment; or from mother to baby at birth.

Hepatitis B can be either acute, generally meaning the virus will leave a person’s body within the first six months, or chronic, in which case it never goes away even if treated.

“It’s important to identify the people at risk in order to treat them and hopefully prevent the long-term consequences of the disease,” Beste says.

The three most common types of viral hepatitis are A, B, and C. Of the three, hepatitis C is most prevalent in the Veteran population and has received much more media coverage and attention in the research community. VA has treated some 120,000 Veterans infected with hepatitis C; more than 100,000 have been cured.

“These high cure rates are largely the result of important new breakthroughs in medications to treat hepatitis C,” Beste explains. “In particular, VA has received much media exposure for its large-scale hepatitis C treatment program.

It’s important to remember that outside of the United States and other developed nations, hepatitis B is much more common than hepatitis C and far surpasses hepatitis C as a cause of liver cancer and liver-related deaths. The hepatitis B infection is a global health care problem, especially in developing areas.”

Unlike hepatitis C, hep B is not curable. In that sense, it’s like the human immunodeficiency virus (HIV), a sexually transmitted infection that can cause AIDS, in that “you can suppress it, but you can almost never get rid of it once you’re chronically infected,” Beste says. “In most cases of hepatitis C, you can take pills, and it’ll be totally gone from your body.”

Hepatitis A is an important and growing cause of liver disease that has resulted in large outbreaks in the U.S. and has affected tens of thousands of people since 2014.

“While hepatitis A does not cause chronic infection, it is extremely contagious and can cause severe acute illness up to and including liver failure and death,” Beste says. “The media excitement surrounding hepatitis C is well-deserved. But I hope for improved public awareness and research attention on A and B, both of which are vaccine-preventable.”

Source: VA Research Currents. Author: Mike Richman. Read the full article, including an interview with patient and Navy Veteran, Natale Stella.