I am greatly appreciative in receiving a
response, let alone from you, the top doctor on HCV within the
VA. Although sir, I respectfully disagree. Your response,
“biologically possible but improbable,” has been the reflexive
response of the VA not only for HCV but for every other large
epidemic within the VA since WWII.
As already discussed VA Cooperative Study 488
only accessed 52 veterans with HCV and is grossly outdated and
does not represent the 74,000 veterans that joined VHA after
Boscarino and colleagues (2014) conducted a study
titled, “Risk Factors for Hepatitis C Infection Among Vietnam
Era Veterans Versus Nonveterans: Results from the Chronic
Hepatitis Cohort Study (CHeCS).” Like Dominitz and Briggs’
studies, Boscarino had patients fill-out questionnaires to
identify HCV risk factors. Boscarino assessed 526 veterans with
Boscarino’s study implicated the jet injector as
a risk factor amongst veterans. “Among veterans reporting
‘other’ exposures, the reason for this was primarily due to
veterans reporting exposure to vaccinations or shots in the
“Vaccinations in the military during the Vietnam
War era were often done with pneumatic
air-guns, en masse, during military induction and
prior to overseas deployments. Typically, service members
received multiple injections as they moved through these
vaccination lines. Given this vaccination method, it was not
uncommon for veterans to be bleeding by the time they reached
the end of the line.”
The researcher stated, “it is noteworthy that
neither history of drug abuse treatment nor history of injection
drug use was associated with Vietnam era veteran status…studies
related to the prevalence of risk factors for HCV among veterans
may be biased [hence, referring to Dominitz and Briggs’
studies]. While our findings are not conclusive and may reflect
recall, response, and/or sampling biases, they may justify the
need for additional research. It is important to stress that the
military service exposure findings found for the Vietnam era
veterans was not part of our original survey design, but emerged
from the coding and analysis of open-ended responses after
Obviously, you will find some objection to this
study for a rebuttal to discredit the jet injector. So lets set
the epidemiological studies aside.
Bottom line: A risk factor is a risk factor,
plain and simple. I am not talking about determining the
etiology of veterans’ HCV. I am talking precisely about the
inconsistent identification of the jet injector as a risk factor
for hepatitis C by VA employees. Some VA staff appropriately
acknowledge the jet injector as a risk factor and others
erroneously discredit it.
The VA would never allow its staff to recognize
the nexus of, per se, blood transfusions and HCV in one case but
discredit this same exact nexus in another case. Doing so would
be preposterous. Yet this is what is occurring with jet
injectors. To allow this inconsistency to remain within VA is
iniquitous. Any blood-to-blood contamination poses a risk of
MANY have acknowledged the jet injector as a risk
factor. The VA is the only agency that does not accurately
recognize the risks and hazards of jet injectors.
Patents for newer generation jet injectors with
disposable parts, known as disposable cartridge jet injectors (DCJI)
implicate prior jet injectors with reusable parts as being
inherently unsafe. See:
-Dunlap KW. “Dry Disposable nozzle assembly for
medical jet injector.” United States Patent 5,062,830. 5
-Landau S. “Multiple use needle-less hypodermic
injection device for individual users.” United States Patent
5,782,802. 21 July 1998.
-Smoliarov BV, Rogatchev VT, Katov VN, Felton A,
Leon N. “Method and apparatus for removing cap from medical
device.” United States Patent 6,626,871 B1. 30 September 2003.
Or look at Mitragotri’s 2006 study which captured
through microcinematography that during a jet injection there is
extensive splash-back of fluid. That is to say after the fluid
penetrates the skin it splashes back on to the jet injector
nozzle and into the nozzle orifice. (Mitragotri S. Current
status and future prospects of needle-free liquid jet injectors.
Nature Reviews Drug Discovery 5:543–548, 2006.)
These findings have been substantiated in
published studies by:
-Hoffman PN, Abuknesha RA, Andrews NJ, Samuel D,
Lloyd JS. A model to assess the infection potential of jet
injectors used in mass immunization. Vaccine 19 (2001):
-Suria H, Van Enk R, Gordon R, Mattano LA Jr.
Risk of cross-patient infection with clinical use of a
needleless injector device. Am J Infect Control. 1999 Oct;
-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,
This finding was even noted in the 1962 patent by
Aaron Ismach, the co-inventor of the Ped-O-Jet, the most widely
used jet injector within the DoD. Ismach claimed his injector
prevented “sucking fluid back from a patient either during or
after the firing cycle.” (see: Ismach, Aaron. “Multi-dose jet
injection device.” United States Patent 3,057,349. 9 October
However, Hoffman’s study found retrograde flow,
aka splash-back, did occur in the Ped-O-Jet.
Sir, I can go on and on. There is an abundance of
evidence demonstrating that jet injectors widely used within the
DoD from 1955 to 1997 contained inherent risks that allowed the
devices to act as vehicles for the cross-contamination of blood
and blood-borne pathogens.
I am asking that the jet injector be officially
recognized by the VA as a risk factor.
In so doing, 42,000 veterans unknowingly living
with HCV will, hopefully, come forward and be tested; will
prevent obfuscating the real risk factors of HCV by vague
classifications such as “Vietnam era veterans;” and will create
consistency throughout all VA employees.
This is the ethical and moral response to take.
In no way will this change the weighing of veterans risk
factors. The willful misconduct of veterans will still be noted
and appropriately weighed.
After all these years will you, acting as the
authority of the VA, finally and appropriately officially
recognize the jet injector as a risk factor for HCV?
P.S. I have another topic to discuss with you after this one.
CC: Senator Schumer
We have received no further
communication as of February 18. 2016..
Response from Dr. Ross - June 22, 2016
Dear Mr. Brown,
While this is not a direct response to your request below, I
wanted to give you a quick update about your e-mail below. I’m
in the process of pulling together a meeting of VA subject
matter experts on this subject to provide information to
Secretary McDonald. I agree with you that this issue is
important and know that it is one that you have spent
considerable time researching. I will work to move this forward.
David Ross, M.D., Ph.D., M.B.I.
Director, HIV, Hepatitis, and Public Health Pathogens Programs
Office of Patient Care Services (10P4I)
U.S. Department of Veterans Affairs
Staff Physician, Infection
Washington, DC VA Medical Center
Associate Clinical Professor of Medicine
George Washington University School of Medicine and Health
1717 H Street,
NW Washington, DC 20006
Mailing Address: 810 Vermont Avenue NW, Washington, DC 20420