John F. Mazzuchi, Ph.D.

Deputy Assistant Secretary of Defense
Statement on Hepatitis C

It is my pleasure today to provide testimony before this subcommittee regarding hepatitis C virus infection in the military. I will provide a brief overview of the epidemiology of the hepatitis C virus in the military population and the related testing, treatment and research programs within the Department of Defense. I am joined today by Colonel Maria Sjogren, Medical Corps, U.S. Army, a gastroenterologist and the Chief of the Department of Clinical Investigation at Walter Reed Army Medical Center, and Major Lianne Groshel, Biomedical Science Corps, U.S. Air Force, a laboratory officer and Deputy Director of the Armed Services Blood Program Office. They will be able to answer any specific questions regarding the evaluation, treatment and clinical research available for patients with hepatitis C infection and our hepatitis C testing as part of our blood donor programs, respectively.

Hepatitis C virus infections among military service members mirror those observed in the United States civilian population with the exception that few infections among military members are attributed to injecting drug use. As you know, between 0.2% to 1.0% of the general population and between 0.1% to 0.6% of blood donors in the United States have evidence of hepatitis C infection.

Among 120,343 donors (of whom 86% were military members) at military blood banks during 1996, 466 (0.39%) were repeatedly reactive by the enzyme linked immunoabsorbent assay (ELISA) test for the antibody to hepatitis C during routine laboratory screening of donated blood. This rate among military blood donors is consistent with the experience in the United States population in general.

Several studies have been conducted to determine the prevalence and incidence of hepatitis infection, including hepatitis C infection, among military members over the past decade. Many of those studies were conducted shortly after tests for hepatitis C had become available so that we could determine whether hepatitis C was present among military members at a different rate than the general U.S. population. A study conducted in 1989 documented hepatitis C infection in 0.3% of 1,538 Navy and Marine Corps recruits upon entry into military service. Other studies in general military populations found evidence of hepatitis C infection in: 0.2% of 5,719 military blood donors in 1990 and 1991; 0.4% of 2,072 shipboard

personnel in 1989 and 1990; and, 0.2% of 2,875 Marines on Okinawa between 1988 and 1990. Among 470 military personnel reporting to a sexually transmitted diseases clinic in the Western Pacific in 1990 and 1991, 1.1% had evidence of hepatitis C infection. Those studies found no evidence that foreign travel or other geographic risk factors placed military members at increased risk for hepatitis C infection. In a study conducted by the Centers for Disease Control and Prevention and the Walter Reed Army Institute of Research, there was no serologic evidence of new hepatitis C infections among 513 soldiers who had deployed to Somalia in 1993.

The Department has reviewed its accession and retention policy with respect to hepatitis C. Hepatitis, which would include hepatitis C, within the preceding six months or persistence of symptoms after six months, with objective evidence of impairment of liver function, and chronic hepatitis are disqualifying conditions for accession. The disability and retention standards identify hepatitis with persistent symptoms or persistent evidence of impaired liver function or the persistence of biochemical markers indicating chronicity as potentially disqualifying for retention. We do not presently test applicants for military service prior to enlistment or recruits in training for the presence of hepatitis C infection. We do not plan to initiate testing because of the low prevalence of infection among our military population and the high cost of a serologic screening program. As part of their medical evaluations, applicants and recruits are asked about any history of hepatitis.

We do not routinely test military members for evidence of hepatitis C infection. The presence of hepatitis C infection is usually discovered when members donate blood, as hepatitis C testing is conducted as a required part of the blood donor program, or is discovered during a clinical evaluation for symptoms or signs of an illness.

When clinically indicated, military members do receive testing and, if appropriate, treatment for hepatitis C infection. Similarly, military members found to be infected with hepatitis C during testing of their donated blood are clinically evaluated and treated, as appropriate. For military members already on active duty, hepatitis C infection by itself does not render them unfit for continued military

service. They will be evaluated to determine the severity of their infection and any related liver injury, and to determine if they warrant limitations on their duties during their treatment and follow-up care.

We have no evidence that military service places members at an increased risk of hepatitis C infection. Nationally, the most efficient modes of hepatitis C transmission are transfusion or transplantation from an infectious donor and injecting drug use. Healthcare workers are at increased risk of hepatitis C infection following needlestick injuries involving infectious patients. Sexual and household contacts of persons with hepatitis C infection are at increased risk for infection, but the magnitude of this risk is not well defined. Persons with multiple sexual partners are also at increased risk. Hepatitis C infection is more common among persons living in Southwest Asia, Africa, Eastern Europe, and South America, than among persons living in more developed countries.

The risk factor of injecting drug use is extremely low among military members. Accession standards, including the requirement to be free of HIV infection, and our drug testing programs exclude most persons who previously used or currently use illicit drugs. The 1995 Department of Defense Survey of Health Related Behaviors among Military Personnel is an anonymous survey which has been conducted periodically among active duty military members since 1980. Use of heroin or other opiates was reported by 0.2% of the surveyed military members. The prevalence of any illicit drug use among military members was one-third the rate reported in age-matched civilian populations. Trends in illicit drug use in the military have dropped steadily since 1980.

Physicians at our military medical centers are conducting clinical research on hepatitis C. Those studies are addressing many of the research needs identified in the National Institutes of Health Consensus Statement, Management of Hepatitis C, 1997, including: clinical treatment trials on interferon and combination therapies for hepatitis C, and studies to better elucidate the natural history of hepatitis C infection. Thank you for this opportunity to provide you with information on hepatitis C infection and our programs related to its evaluation, treatment and control. If you have specific questions, Dr. Sjogren, Major Groshel, or I would be happy to answer them.