Epidemiology: Hepatitis C in the Veteran Population
NUR / 408
July 7, 2014
Deborah Nallo

Introduction
Hepatitis C (HCV) is highly prevalent within the Veteran population. HCV is a major public health concern because of the debilitating effects associated with the virus. HCV results in increased mortality and morbidity rates resulting from the acute and chronic effects of the virus. The most common transmission of HCV occurs through injection drug use, injuries resulting from needle sticks and the lack of infection control in healthcare facilities. The transmission of HCV can also occur through sexual contact between individuals who have the human immunodeficiency virus, and HCV virus, tattoos that were not professionally done and HCV infected mothers who have transmitted the virus to their newborn babies. The hepatitis C virus is the most common blood-borne virus in the United States. An estimated 3.2 million people in the United States have chronic hepatitis C. Most are unaware of their infection. Each year, about 17,000 Americans become infected with hepatitis C ("Centers for Disease Control and Prevention", n.d.). The veteran population has a higher rate of HCV exposure and infection when compared to the general population. Many of the individuals who are infected with the HCV virus are unaware of their infection and therefore they do not receive the necessary treatment. Individuals with HCV are at increased risk of developing hepatocellular carcinomas and other liver diseases. Due to the lack of vaccines against HCV, preventing and controlling the spread of HCV is the focus of public health care initiatives. This paper will further detail the epidemiology of Hepatitis C and its prevalence amongst the veteran population.
In a study conducted by the U.S. Department of Veterans Affairs, it concluded that the prevalence of Hepatitis C virus in the Veteran population is higher than the general population. In 1999, HCV surveillance was conducted and over 26,000 veterans were tested for HCV using an antibody assay method. The results of this HCV surveillance day concluded that approximately 6-8% of the population had been infected with HCV. The department of Veteran Affairs continued to screen approximately half a million patients over a year’s span from 1999-2000 and found that 77,000 veterans had chronic hepatitis C. This resulted in the Department of Veterans Affairs treating more patients for hepatitis C than any other healthcare agency (Cheung, 2003). Homeless veterans had a 40% higher prevalence of HCV than the rest of the veteran population. In 2012, the Hepatitis C screening and prevalence among Veterans in the Veterans Affairs Care showed that 2.7-3.9 million Americans are living with HCV infection, a disproportionately high prevalence of HCV infection among persons born in the mid 1940s-mid 1960s, over 75% of Americans with HCV are Baby Boomers, 45-85% of those infected with HCV were unaware that they are infected. Veterans have a higher prevalence of HCV exposure and infection than the general population (Backus, n.d.). Without proper hepatitis C treatment The "Centers for Disease Control and Prevention" (n.d.) website concludes that 1.76 million Americans who have HCV will develop liver cirrhosis, 400, 000 will develop hepatocellular carcinoma, and more than one million will die of hepatitis C related disease. These overwhelming numbers and the prevalence of hepatitis C on a vulnerable population such as the veteran population signify the importance of this issue as a public health concern.
Definition and Description of Epidemiology
“Epidemiology is the science concerned with the study of the factors determining and influencing the frequency and distribution of disease, injury, and other health-related events and their causes in a defined human population. Also, the sum of knowledge gained in such a study’’ ("Epidemiology," 2014). Epidemiology attempts to determine factors associated with the occurrence of certain diseases. Epidemiology only determines the relationship between risk factors that show a higher incidence of diseases in defined populations, thus unable to prove disease causation. The role of the epidemiologist is to find a common links between risk factors such as age, gender, culture, geographical location, vulnerability and diseases occurrence. Epidemiology addresses a range of topics that include disease prevention, health promotions and health care outcomes through descriptive and analytic epidemiological studies. Descriptive epidemiology informs of us the pattern of the disease in reference to the population affected, when, where it occurred, and the outcome. Health determinants that inform us of the how and why the disease occurred include characteristics of the population, common behaviors, and who may be infected showing a cause and association relationship is analytically epidemiology.
Steps and Methods in Epidemiology Descriptive epidemiology methods include the organization of information by person, place, and time and show the distribution of the disease. The defined population is the veterans who attended the national hepatitis surveillance screening day to determine the occurrence of veterans with hepatitis C. The screening took place over a day at Veteran Administration medical centers and determined that 6-8% of the 26,000 that were screened were infected with the hepatitis C virus. Next, they continued screening veterans over a year and found that 77,000 veterans were infected with chronic hepatitis C and those certain subgroups of veterans such homeless veterans and those born between the 1940s and 1960s had a higher incidence of hepatitis C. In 2012, in an effort to meet the Centers for Disease Control and Prevention and the U.S Preventative Services task force recommendation for HCV screening the Veteran administration conducted a study using methods that including data sources such as the birth dates and laboratory test to assess the extent of veterans who had been screened.
Description of the Epidemiology Triangle
The three elements of the epidemiology triangle include the host, agent and the environment. The epidemiology triangle was created to show the relationship between causative factors, disease transmission and risks associated with infectious diseases. The triangle is a reflection of a codependent relationship. Changes occurring in one element of the triangle influence the occurrence of disease by increasing or decreasing a person’s risk for disease (Stanhope, 2012, p. 264). The hepatitis C virus is the infectious agent of the triangle. The host of the hepatitis C virus is the infected veteran. External factors include blood transfusions, and intravenous drug use forms the environment of the triangle. The epidemiology triangle demonstrates a much simplified relationship on disease causation. The web of casualty demonstrates a more complex relationship among multiple factors. The interacting factors can be subtle but still have the influence to increase or decrease disease occurrence (Stanhope, 2012, p. 265).
Type of Epidemiology Used
In determining the prevalence of hepatitis C, in the veteran population descriptive epidemiology was used. Significant results of the study showed that the veteran population had a 6.1% higher prevalence of HCV than the 1.2 % estimates for the general U.S. population. A significant association was shown between those who were born 1945-1965. HCV prevalence was 2.5% higher than the general population who were born 1945-1965 (Backus, n.d.). The person, place and time were depicted in this study. The person being the veteran population, the place being Veterans healthcare facilities and the time focused on veterans who were born 1945-1965.
Population Characteristics Influence Vulnerability Vulnerable populations are those who pose a higher risk of developing health problems. The Centers of Disease Control and Prevention categorize vulnerable populations by socio-economic status, geography, gender, age, disability status and risk status related to sex and gender ("Centers for Disease Control and Prevention", n.d.). Veterans fall into the category of a vulnerable population. There was a significant association made between veterans who were born from 1945-1965 and those that served in the Vietnam War. It is suggested that the increased prevalence of HCV in the Vietnam era is due to advances in medical treatments. Rapid blood transfusion decreased combat casualties but occurred before transfused blood was screened for HCV. Commonalities in medical conditions were associated with HCV infection such as liver disease, and sexual transmitted diseases also the relationship between substance abuse and alcoholism (Waters, 2003).
Cultural Considerations
The cultural of the Veteran population presents with unique needs. Health inequalities and disparities related to substance abuse, HCV, post-traumatic stress disorder and other medical conditions require individualized care. Providing culturally competent care requires understanding differences in the military and civilian populations. Subcultural differences exist within a cultural, cultural competence allows clinicians to increase the efficacy of care provided to the veteran population. Veterans are exposed to unnatural, stressful situation during combat. These situations often lead to psychological concerns within the population. VA records indicate an increase in mental illness, drug abuse and depression in veterans. Treatments tailored to the unique needs of the population will reduce disparities and improve outcomes ("National Alliance on Mental Health Illness", n.d.).
Ethical and Legal Considerations Impacting Health Status
Hepatitis C is the most common blood-borne infection, vulnerable populations such as the veteran population encounter barriers that prevent or delay treatment. A low percent of veterans are treated for HCV. Ethical, social and clinical issues influence HCV treatment. Low treatment rates have been attributed to patient preference, medical and psychiatric concerns, and recent substance abuse (Morrill, n.d.). The current treatment for HCV using antiviral drugs can be effective, but the regimen is difficult. HCV is treated with antiviral therapy and can require a year to treat the virus. The long treatment regimens and harsh side effects of fatigue, depression, rashes and anemia have acted as a deterrent to the veteran population from receiving treatment. Psychiatric issues, substance abuse and non-compliance within the veteran populations have led to the impediment of clinicians starting therapy. Improving compliance rates will take a multidisciplinary approach. Veterans must be educated on the treatment risk and benefits. Side effects require aggressive management, alcoholic abuse and screening programs along with proper psychiatric care. HCV screening process may pose legal and ethical concerns. A screening process that requires veterans to be drug tested blurs the lines of patient privacy rights. Levels of Prevention
According to "Centers For Disease Control And Prevention" (n.d.), “Reducing the burden of HCV infection and HCV-related disease in the United States requires implementation of primary prevention activities to reduce the risk for contracting HCV infection and secondary prevention activities to reduce the risk for liver and other chronic diseases in HCV-infected person” (para. 5). Primary prevention can be challenging in the veteran population due to non-compliance and the high prevalence of drug and alcohol abuse. Primary interventions raise awareness to the community to decrease the transmission of the virus. Blood safety strategies for donation and donor selection and safe injections patterns are interventions in preventative treatment. Secondary prevention by screening veterans that are high risk from serving during the Vietnam era, drug and alcohol abuse provides early diagnosis to provide care that will result in the best outcome. The diagnosed individual can then take steps to prevent the transmission of the disease to the community and prevent the progression of the disease ("World Health Organization", 2012).
Conclusion
The veteran population has a high prevalence of HVC. The epidemiology of HVC allows us to explore to causation factors it relation to this venerable population. The epidemiology triangle gives us a basic overview of the relationship between the agent, host, and the environment. It is the role of the epidemiologist to break this link to prevent disease transmission. Because the veteran population has unique healthcare needs, treatment and prevention can be challenging to healthcare workers. Ethical, legal, and cultural issues are taken into consideration to provide culturally competent care that enables veterans to have the best outcomes.

References
Backus, L. I. (n.d.). U.S. Department of Veterans Affairs. Retrieved from http://U.S. Department of Veterans Affairs. (n.d.). Retrieved from http://www.publichealth.va.gov/docs/populationhealth/hepatitis/AASLD-2013-HCV-screen-oral-11-03-2013.pdf
Centers for Disease Control and Prevention. (n.d.). Retrieved from http://www.cdc.gov/hepatitis/Statistics/2011Surveillance/Commentary.htm
Centers for Disease Control and Prevention. (n.d.). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm
Centers for Disease Control and Prevention. (n.d.). Retrieved from http://www.cdc.gov/minorityhealth/populations.html
Cheung, R. C. (2003). HCV Advocate. Retrieved from http://www.hcvadvocate.org/hcsp/articles/cheung-1.html
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Morrill, J. A. (n.d.). U.S. National Library of Medicine National Institute of Health. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490173/#b8
National Alliance on Mental Health Illness. (n.d.). Retrieved from http://nami.org/Content/NavigationMenu/Find_Support/Veterans_Resources/Multicultural_Issues/Veterans_of_Culturally_Diverse_Populations.htm

Stanhope, M. (2012). Public Health Nursing: Population-Centered Health Care in the Community (8th ed.). Retrieved from The University of Phoenix ebook Collection database.
Waters, B. (2003). HCV Advocate. Retrieved from http://www.hcvadvocate.org/hcsp/articles/vietvet.html
World Health Organization. (2012). Retrieved from http://www.who.int/csr/disease/hepatitis/GHP_framework.pdf

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