Statement of Principles

concerning

ISCHAEMIC HEART DISEASE
(Balance of Probabilities)

(No. 2 of 2016)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans’ Entitlements Act 1986.

Dated 18 December                                                                                                                                                                                                                                               2015

The Common Seal of the
Repatriation Medical Authority
was affixed to this instrument
at the direction of:

Professor Nicholas Saunders AO

Chairperson

Contents

1 Name

2 Commencement

3 Authority

4 Revocation

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning ischaemic heart disease (Balance of Probabilities) (No. 2 of 2016).

2               Commencement

              This instrument commences on 25 January 2016.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans’ Entitlements Act 1986.

4               Revocation

The Statement of Principles concerning ischaemic heart disease No. 90 of 2007, as amended, made under subsections 196B(3) and (8) of the VEA is revoked.

5               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about ischaemic heart disease and death from ischaemic heart disease.

Meaning of ischaemic heart disease

(2)          For the purposes of this Statement of Principles, ischaemic heart disease means a cardiac disability characterised by insufficient blood flow to the muscle tissue of the heart due to atherosclerosis, thrombosis, vasospasm or dissection of the coronary arteries.

(3)          While ischaemic heart disease attracts ICD‑10‑AM code I20 to I25, in applying this Statement of Principles the meaning of ischaemic heart disease is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD‑10‑AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM), Ninth Edition, effective date of 1 July 2015, copyrighted by the Independent Hospital Pricing Authority, ISBN 978‑1‑76007‑020‑5.

Death from ischaemic heart disease

(5)          For the purposes of this Statement of Principles, ischaemic heart disease, in relation to a person, includes death from a terminal event or condition that was contributed to by the person’s ischaemic heart disease.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that ischaemic heart disease and death from ischaemic heart disease can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: relevant service is defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, ischaemic heart disease or death from ischaemic heart disease is connected with the circumstances of a person’s relevant service:

(1)          having hypertension before the clinical onset of ischaemic heart disease;

(2)          having diabetes mellitus before the clinical onset of ischaemic heart disease;

(3)          being obese for at least five years within the 15 years before the clinical onset of ischaemic heart disease;

Note: being obese is defined in the Schedule 1 - Dictionary.               

(4)          having dyslipidaemia before the clinical onset of ischaemic heart disease;

Note: dyslipidaemia is defined in the Schedule 1 - Dictionary.             

(5)          where smoking has not ceased prior to the clinical onset of ischaemic heart disease:

(a)          smoking an average of at least three cigarettes per day, or the equivalent thereof in other tobacco products, for at least the one year before the clinical onset of ischaemic heart disease; or

(b)          smoking at least one half pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ischaemic heart disease;

Note: cigarettes per day, or the equivalent thereof in other tobacco products and pack-year of cigarettes, or the equivalent thereof in other tobacco products are defined in the Schedule 1 - Dictionary.             

(6)          where smoking has ceased prior to the clinical onset of ischaemic heart disease:

(a)          smoking at least one half pack-year but less than five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ischaemic heart disease, and the clinical onset of ischaemic heart disease has occurred within five years of smoking cessation;

(b)          smoking at least five pack-years but less than 20 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ischaemic heart disease, and the clinical onset of ischaemic heart disease has occurred within 20 years of smoking cessation; or

(c)          smoking at least 20 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of ischaemic heart disease;

Note: pack-year of cigarettes, or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary.             

(7)          where exposure to second-hand smoke has not ceased, being exposed to second-hand smoke for at least 1 000 hours before the clinical onset of ischaemic heart disease;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(8)          where exposure to second-hand smoke has ceased:

(a)          being exposed to second-hand smoke for at least 1 000 hours but less than 5 000 hours before the clinical onset of ischaemic heart disease, and the clinical onset of ischaemic heart disease has occurred within five years of the last exposure to second-hand smoke; or

(b)          being exposed to second-hand smoke for at least 5 000 hours before the clinical onset of ischaemic heart disease;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(9)          where the use of chewing tobacco has not ceased, using chewing tobacco on more days than not for at least one year before the clinical onset of ischaemic heart disease;

(10)      where the use of chewing tobacco has ceased:

(a)          using chewing tobacco on more days than not for at least one year but less than five years before the clinical onset of ischaemic heart disease, and the clinical onset of ischaemic heart disease has occurred within five years of ceasing to use chewing tobacco; or

(b)          using chewing tobacco on more days than not for at least five years before the clinical onset of ischaemic heart disease;

(11)      an inability to undertake any physical activity greater than three METs for at least the five years before the clinical onset of ischaemic heart disease;

Note: MET is defined in the Schedule 1 - Dictionary.

(12)      being sedentary for a cumulative total of at least 12 hours per day on more days than not for at least the five years before the clinical onset of ischaemic heart disease;

Note: being sedentary is defined in the Schedule 1 - Dictionary.

(13)      having chronic kidney disease before the clinical onset of ischaemic heart disease;

Note: chronic kidney disease is defined in the Schedule 1 - Dictionary.

(14)      having hypothyroidism or Hashimoto's thyroiditis with hypothyroidism for at least two years within the ten years before the clinical onset of ischaemic heart disease;

(15)      having received a cumulative equivalent dose of at least 1 sievert of ionising radiation to the heart at least one year before the clinical onset of ischaemic heart disease;

Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary.

(16)      undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical onset of ischaemic heart disease;

(17)      having a clinically significant disorder of mental health as specified for at least the five years before the clinical onset of ischaemic heart disease;

Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.

(18)      using a combined oral contraceptive pill containing at least 30 micrograms of ethinyl oestradiol for at least the 21 days before the clinical onset of ischaemic heart disease;

(19)      being treated with a drug, or a drug from a class of drugs, from Specified List 1 of drugs, where that drug cannot be ceased or substituted, at the time of the clinical onset of ischaemic heart disease;

Note: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary.

(20)      using a drug belonging to the non-steroidal anti-inflammatory class of drugs, excluding aspirin, paracetamol and topical non-steroidal anti-inflammatory drugs, for a continuous period of at least seven days before the clinical onset of ischaemic heart disease, where the last dose of the drug within that period was taken within the seven days before the clinical onset of ischaemic heart disease;

(21)      having bilateral orchiectomy before the clinical onset of ischaemic heart disease;

(22)      having antiandrogen therapy with a gonadotrophin releasing hormone agonist (including goserelin and leuprorelin) for at least the seven days before the clinical onset of ischaemic heart disease;

(23)      having thrombosis of a coronary artery as a result of being in a hypercoagulable state as specified at the time of the clinical onset of ischaemic heart disease;

Note: hypercoagulable state as specified is defined in the Schedule 1 - Dictionary.

(24)      inhaling ambient chronically polluted air as specified for at least 2 000 hours within the five years before the clinical onset of ischaemic heart disease;

Note: ambient chronically polluted air as specified is defined in the Schedule 1 - Dictionary.

(25)      an inability to consume an average of at least 100 grams per day of vegetables or fruits, for at least the five years before the clinical onset of ischaemic heart disease;

(26)      an inability to consume an average of at least 100 grams of fish per fortnight for at least the five years before the clinical onset of ischaemic heart disease;

(27)      an inability to sleep for an average of at least five hours daily for at least the one year before the clinical onset of ischaemic heart disease;

(28)      being infected with human immunodeficiency virus for at least five years before the clinical onset of ischaemic heart disease;

(29)      having periodontitis for at least the five years before the clinical onset of ischaemic heart disease;

(30)      having infective endocarditis or syphilis involving the coronary arteries at the time of the clinical onset of ischaemic heart disease;

(31)      undergoing a procedure involving catheterisation of the affected coronary artery within the five years before the clinical onset of ischaemic heart disease;

(32)      having a specified autoimmune collagen vascular disease at the time of the clinical onset of ischaemic heart disease;

Note: specified autoimmune collagen vascular disease is defined in the Schedule 1 - Dictionary.

(33)      for angina, acute myocardial infarction or sudden death from ischaemic heart disease only:

(a)          undertaking physical activity of six METs or more within the 12 hours before the clinical onset of ischaemic heart disease;

(b)          experiencing a category 1A stressor within the 12 hours before the clinical onset of ischaemic heart disease;

(c)          experiencing a category 1B stressor within the 12 hours before the clinical onset of ischaemic heart disease;

(d)          experiencing an acute, severe, emotional stressor within the 12 hours before the clinical onset of ischaemic heart disease;

(e)          experiencing the death of a significant other within the six months before the clinical onset of ischaemic heart disease;

(f)           using a drug from Specified List 2 of drugs within the 24 hours before the clinical onset of ischaemic heart disease;

(g)          having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the seven days before the clinical onset of ischaemic heart disease;

(h)          being exposed to:

(i)            an environment of extreme heat during a heatwave; or

(ii)         an environment of extreme cold during a cold snap; or

(iii)       an abrupt alteration of temperature by ten degrees Celsius or more, to extreme heat or to extreme cold;

for a period of at least six hours within the seven days before the clinical onset of ischaemic heart disease;

(i)            inhaling ambient highly polluted air as specified for at least two hours within the seven days before the clinical onset of ischaemic heart disease;

(j)            being envenomated by a snake, scorpion, wasp, bee, hornet, spider, fish or jellyfish within the 24 hours before the clinical onset of ischaemic heart disease;

(k)          having an acute hypersensitivity reaction involving the coronary arteries as a result of being exposed to a drug, food or environmental agent from the specified list within the 12 hours before the clinical onset of ischaemic heart disease;

(l)            having influenza or a lower respiratory tract infection within the 30 days before the clinical onset of ischaemic heart disease; or

(m)        being pregnant within the six weeks before the clinical onset of ischaemic heart disease;

Note: acute cholinergic poisoning; acute, severe, emotional stressor; ambient highly polluted air as specified; category 1A stressor; category 1B stressor; cold snap; drug, food or environmental agent from the specified list; extreme cold; extreme heat; heatwave; organophosphorus ester; MET; significant other and Specified List 2 of drugs are defined in the Schedule 1 - Dictionary.             

(34)      having hypertension before the clinical worsening of ischaemic heart disease;

(35)      having diabetes mellitus before the clinical worsening of ischaemic heart disease;

(36)      being obese for at least five years within the 15 years before the clinical worsening of ischaemic heart disease;

Note: being obese is defined in the Schedule 1 - Dictionary.               

(37)      having dyslipidaemia before the clinical worsening of ischaemic heart disease;

Note: dyslipidaemia is defined in the Schedule 1 - Dictionary.             

(38)      where smoking has not ceased prior to the clinical worsening of ischaemic heart disease:

(a)          smoking an average of at least three cigarettes per day, or the equivalent thereof in other tobacco products, for at least the one year before the clinical worsening of ischaemic heart disease; or

(b)          smoking at least one half pack-year of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ischaemic heart disease;

Note: cigarettes per day, or the equivalent thereof in other tobacco products and pack-year of cigarettes, or the equivalent thereof in other tobacco products are defined in the Schedule 1 - Dictionary.             

(39)      where smoking has ceased prior to the clinical worsening of ischaemic heart disease:

(a)          smoking at least one half pack-year but less than five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ischaemic heart disease, and the clinical worsening of ischaemic heart disease has occurred within five years of smoking cessation;

(b)          smoking at least five pack-years but less than 20 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ischaemic heart disease, and the clinical worsening of ischaemic heart disease has occurred within 20 years of smoking cessation; or

(c)          smoking at least 20 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of ischaemic heart disease;

Note: pack-year of cigarettes, or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary.             

(40)      where exposure to second-hand smoke has not ceased, being exposed to second-hand smoke for at least 1 000 hours before the clinical worsening of ischaemic heart disease;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(41)      where exposure to second-hand smoke has ceased:

(a)          being exposed to second-hand smoke for at least 1 000 hours but less than 5 000 hours before the clinical worsening of ischaemic heart disease, and the clinical worsening of ischaemic heart disease has occurred within five years of the last exposure to second-hand smoke; or

(b)          being exposed to second-hand smoke for at least 5 000 hours before the clinical worsening of ischaemic heart disease;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(42)      where the use of chewing tobacco has not ceased, using chewing tobacco on more days than not for at least one year before the clinical worsening of ischaemic heart disease;

(43)      where the use of chewing tobacco has ceased:

(a)          using chewing tobacco on more days than not for at least one year but less than five years before the clinical worsening of ischaemic heart disease, and the clinical worsening of ischaemic heart disease has occurred within five years of ceasing to use chewing tobacco; or

(b)          using chewing tobacco on more days than not for at least five years, before the clinical worsening of ischaemic heart disease;

(44)      an inability to undertake any physical activity greater than three METs for at least the five years before the clinical worsening of ischaemic heart disease;

Note: MET is defined in the Schedule 1 - Dictionary.

(45)      being sedentary for a cumulative total of at least 12 hours per day on more days than not for at least the five years before the clinical worsening of ischaemic heart disease;

Note: being sedentary is defined in the Schedule 1 - Dictionary.

(46)      having chronic kidney disease before the clinical worsening of ischaemic heart disease;

Note: chronic kidney disease is defined in the Schedule 1 - Dictionary.

(47)      having hypothyroidism or Hashimoto's thyroiditis with hypothyroidism for at least two years within the ten years before the clinical worsening of ischaemic heart disease;

(48)      having received a cumulative equivalent dose of at least 1 sievert of ionising radiation to the heart at least one year before the clinical worsening of ischaemic heart disease;

Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary.

(49)      undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical worsening of ischaemic heart disease;

(50)      having a clinically significant disorder of mental health as specified for at least the five years before the clinical worsening of ischaemic heart disease;

Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.

(51)      using a combined oral contraceptive pill containing at least 30 micrograms of ethinyl oestradiol for at least the 21 days before the clinical worsening of ischaemic heart disease;

(52)      being treated with a drug, or a drug from a class of drugs, from Specified List 1 of drugs, where that drug cannot be ceased or substituted, at the time of the clinical worsening of ischaemic heart disease;

Note: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary.

(53)      using a drug belonging to the non-steroidal anti-inflammatory class of drugs, excluding aspirin, paracetamol and topical non-steroidal anti-inflammatory drugs, for a continuous period of at least seven days before the clinical worsening of ischaemic heart disease, where the last dose of the drug within that period was taken within the seven days before the clinical worsening of ischaemic heart disease;

(54)      having bilateral orchiectomy before the clinical worsening of ischaemic heart disease;

(55)      having antiandrogen therapy with a gonadotrophin releasing hormone agonist (including goserelin and leuprorelin) for at least the seven days before the clinical worsening of ischaemic heart disease;

(56)      having thrombosis of a coronary artery as a result of being in a hypercoagulable state as specified at the time of the clinical worsening of ischaemic heart disease;

Note: hypercoagulable state as specified is defined in the Schedule 1 - Dictionary.

(57)      inhaling ambient chronically polluted air as specified for at least 2 000 hours within the five years before the clinical worsening of ischaemic heart disease;

Note: ambient chronically polluted air as specified is defined in the Schedule 1 - Dictionary.

(58)      an inability to consume an average of at least 100 grams per day of vegetables or fruits, for at least the five years before the clinical worsening of ischaemic heart disease;

(59)      an inability to consume an average of at least 100 grams of fish per fortnight for at least the five years before the clinical worsening of ischaemic heart disease;

(60)      an inability to sleep for an average of at least five hours daily for at least the one year before the clinical worsening of ischaemic heart disease;

(61)      being infected with human immunodeficiency virus for at least five years before the clinical worsening of ischaemic heart disease;

(62)      having periodontitis for at least the five years before the clinical worsening of ischaemic heart disease;

(63)      having infective endocarditis or syphilis involving the coronary arteries at the time of the clinical worsening of ischaemic heart disease;

(64)      undergoing a procedure involving catheterisation of the affected coronary artery within the five years before the clinical worsening of ischaemic heart disease;

(65)      having a specified autoimmune collagen vascular disease at the time of the clinical worsening of ischaemic heart disease;

Note: specified autoimmune collagen vascular disease is defined in the Schedule 1 - Dictionary.

(66)      for acute myocardial infarction or sudden death from ischaemic heart disease only:

(a)          undertaking physical activity of six METs or more within the 12 hours before the clinical worsening of ischaemic heart disease;

(b)          experiencing a category 1A stressor within the 24 hours before the clinical worsening of ischaemic heart disease;

(c)          experiencing a category 1B stressor within the 24 hours before the clinical worsening of ischaemic heart disease;

(d)          experiencing an acute, severe, emotional stressor within the 12 hours before the clinical worsening of ischaemic heart disease;

(e)          experiencing the death of a significant other within the six months before the clinical worsening of ischaemic heart disease;

(f)           using a drug from Specified List 2 of drugs within the 24 hours before the clinical worsening of ischaemic heart disease;

(g)          having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the seven days before the clinical worsening  of ischaemic heart disease;

(h)          being exposed to:

(i)            an environment of extreme heat during a heatwave; or

(ii)         an environment of extreme cold during a cold snap; or

(iii)       an abrupt alteration of temperature by ten degrees Celsius or more, to extreme heat or to extreme cold;

for a period of at least six hours within the seven days before the clinical worsening of ischaemic heart disease;

(i)            inhaling ambient highly polluted air as specified for at least two hours within the seven days before the clinical worsening of ischaemic heart disease;

(j)            being envenomated by a snake, scorpion, wasp, bee, hornet, spider, fish or jellyfish within the 24 hours before the clinical worsening of ischaemic heart disease;

(k)          having an acute hypersensitivity reaction involving the coronary arteries as a result of being exposed to a drug, food or environmental agent from the specified list within the 12 hours before the clinical worsening of ischaemic heart disease;

(l)            having influenza or a lower respiratory tract infection within the 30 days before the clinical worsening of ischaemic heart disease; or

(m)        being pregnant within the six weeks before the clinical worsening of ischaemic heart disease;

Note: acute cholinergic poisoning; acute, severe, emotional stressor; ambient highly polluted air as specified; category 1A stressor; category 1B stressor; cold snap; drug, food or environmental agent from the specified list; extreme cold; extreme heat; heatwave; organophosphorus ester; MET; significant other and Specified List 2 of drugs are defined in the Schedule 1 - Dictionary.             

(67)      inability to obtain appropriate clinical management for ischaemic heart disease.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 9(34) to 9(67) apply only to material contribution to, or aggravation of, ischaemic heart disease where the person’s ischaemic heart disease was suffered or contracted before or during (but did not arise out of) the person’s relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                               acute cholinergic poisoning means symptoms and signs due to the inhibition of acetylcholinesterase enzyme activity which occur within the 24 hours following exposure.  These symptoms and signs are: acute paralysis, overwhelming bronchial secretions, bradycardia, gastrointestinal distress, miosis, lacrimation or diarrhoea.

                               acute, severe, emotional stressor means an event which causes a sudden, intense emotional or psychological response, such as an emergency incident or an emotionally charged situation.

                               ambient chronically polluted air as specified means air with average annual concentrations of particulate matter with an aerodynamic diameter of < 2.5 µm (PM2.5) exceeding 8 µg/m3.

                               ambient highly polluted air as specified means air with 24 hour average concentrations of:

(a)          particulate matter with an aerodynamic diameter of < 2.5 µm (PM2.5) exceeding 25 µg/m3; or

(b)          particulate matter with an aerodynamic diameter of < 10 µm (PM10) exceeding 50 µg/m3.

                               amphetamines as specified means any one of the following drugs:

(a)          3,4-methylenedioxymethamphetamine (ecstasy);

(b)          crystal methamphetamine (ice);

(c)          methamphetamine (speed); or

(d)          paramethoxymethamphetamine.

                               being exposed to second-hand smoke means being in an enclosed space and inhaling smoke from burning tobacco products or smoke that has been exhaled by a person who is smoking.

                               being obese means:

(a)          having a Body Mass Index (BMI) of 30 or greater; or

(b)          for males, having a waist circumference exceeding 102 centimetres; or

(c)          for females, having a waist circumference exceeding 88 centimetres.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               being sedentary means waking behaviour characterised by an average energy expenditure of 1.5 METs or less while in a sitting or reclining posture.

                               BMI means W/H2 and where:

                               W is the person's weight in kilograms; and

                               H is the person's height in metres.

                               category 1A stressor means one of the following severe traumatic events:

(a)          experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)          being threatened with a weapon, being held captive, being kidnapped, or being tortured.

                               category 1B stressor means one of the following severe traumatic events:

(a)          being an eyewitness to a person being killed or critically injured;

(b)          viewing corpses or critically injured casualties as an eyewitness;

(c)          being an eyewitness to atrocities inflicted on another person or persons;

(d)          killing or maiming a person; or

(e)          being an eyewitness to or participating in, the clearance of critically injured casualties.

Note: eyewitness is also defined in the Schedule 1 - Dictionary.

                               chronic kidney disease means having a glomerular filtration rate of less than 60 mL/min/1.73 m2 for a period of at least three months, or the presence of irreversible kidney damage.

                               cigarettes per day, or the equivalent thereof in other tobacco products means either cigarettes, pipe tobacco or cigars, alone or in any combination, where one tailor-made cigarette approximates one gram of tobacco; or one gram of cigar, pipe or other smoking tobacco.

                               clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management, which may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner:

(a)          agoraphobia;

(b)          anxiety disorder;

(c)          depressive disorder;

(d)          panic disorder;

(e)          posttraumatic stress disorder;

(f)           schizophrenia; or

(g)          social anxiety disorder.

                               cold snap means three or more days of unusually low maximum and minimum temperatures.

                               cumulative equivalent dose means the total dose of ionising radiation received by the particular organ or tissue.  The formula used to calculate the cumulative equivalent dose allows doses from multiple types of ionising radiation to be combined, by accounting for their differing biological effect.  The unit of equivalent dose is the sievert.  For the purposes of this Statement of Principles, the calculation of cumulative equivalent dose excludes doses received from normal background radiation, but includes therapeutic radiation, diagnostic radiation, cosmic radiation at high altitude, radiation from occupation-related sources and radiation from nuclear explosions or accidents.

                               drug, food or environmental agent from the specified list means:

(a)          beta-lactam antibiotics;

(b)          histidine contaminated fish (scombroid syndrome);

(c)          latex;

(d)          succinylated gelatin (Gelofusine); or

(e)          other drug, food or agent where there is evidence of an associated systemic allergic reaction.

                               dyslipidaemia means persistently abnormal blood lipid levels, diagnosed by a medical practitioner and evidenced by:

(a)          a total serum cholesterol level greater than 5.5 mmol/L; or

(b)          a serum low density lipoprotein level greater than 4.0 mmol/L; or

(c)          a serum high density lipoprotein cholesterol level less than 1.0 mmol/L; or

(d)          the regular administration of drug therapy to normalise blood lipid levels.

                               extreme cold means zero degrees Celsius or below.

                               extreme heat means 40 degrees Celsius or above.

                               eyewitness means a person who observes an incident first hand and can give direct evidence of it.  This excludes a person exposed only to media coverage of the incident.

                               heatwave means three or more days of unusually high maximum and minimum temperatures.

                               hypercoagulable state as specified means any one of the following:

(a)          acquired activated protein C resistance;

(b)          acquired antithrombin III deficiency;

(c)          acquired dysfibrinogenaemia;

(d)          acquired protein C deficiency;

(e)          acquired protein S deficiency;

(f)           antiphospholipid syndrome;

(g)          aplastic anaemia;

(h)          disseminated intravascular coagulation;

(i)            essential thrombocythaemia;

(j)            haemolytic uraemic syndrome;

(k)          heparin-induced thrombocytopaenia;

(l)            hyperfibrinogenaemia;

(m)        hyperproteinaemia;

(n)          hyperviscosity syndrome;

(o)          immune thrombocytopaenic purpura;

(p)          myeloma;

(q)          myeloproliferative disease;

(r)           nephrotic syndrome;

(s)           paroxysmal nocturnal haemoglobinuria;

(t)            polycythaemia vera;

(u)          secondary thrombocytosis; or

(v)          sickle cell disorder.

                               ischaemic heart disease—see subsection 7(2).

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               MET means a unit of measurement of the level of physical exertion.  1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour or resting metabolic rate.

                               organophosphorus ester means an agent used to inhibit acetylcholinesterase, and includes the organophosphate pesticides chlorpyrifos, dichlorvos, EPN (ethyl p-nitrophenyl theonobenzenephosphonate), leptophos, methamidophos, mipafox (diisopropyl phosphorofluoridate), omethoate, parathion, TOCP (tri-ortho-cresyl phosphate), trichlorfon and trichlornat.

                               pack-year of cigarettes, or the equivalent thereof in other tobacco products means a calculation of consumption where one pack-year of cigarettes equals 20 tailor-made cigarettes per day for a period of one calendar year, or 7 300 cigarettes.  One tailor-made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight.  One pack-year of tailor-made cigarettes equates to 7.3 kilograms of smoking tobacco by weight.  Tobacco products mean cigarettes, pipe tobacco or cigars, smoked alone or in any combination.

                               relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime service under the MRCA.

                               significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                               specified autoimmune collagen vascular disease means:

(a)          ankylosing spondylitis;

(b)          Behcet's syndrome;

(c)          dermatomyositis;

(d)          eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome);

(e)          giant cell (temporal) arteritis;

(f)           Henoch-Schönlein purpura;

(g)          microscopic polyangiitis;

(h)          mucocutaneous lymph node syndrome (Kawasaki's disease);

(i)            non-specific autoimmune vasculitis;

(j)            polyarteritis nodosa;

(k)          polymyositis;

(l)            rheumatoid arthritis;

(m)        Sjögren's syndrome;

(n)          systemic lupus erythematosus;

(o)          systemic sclerosis;

(p)          Takayasu's arteritis;

(q)          thromboangiitis obliterans (Buerger's disease); or

(r)           Wegener's granulomatosis.

                               Specified List 1 of drugs means:

(a)          antipsychotics;

(b)          aromatase inhibitors;

(c)          bevacizumab;

(d)          capecitabine;

(e)          docetaxel;

(f)           ephedrine;

(g)          ergotamine;

(h)          erlotinib;

(i)            fluorouracil;

(j)            paclitaxel;

(k)          phentermine;

(l)            pseudoephedrine;

(m)        sorafenib; or

(n)          triptans, including sumatriptan.

                               Specified List 2 of drugs means:

(a)          amphetamines as specified;

(b)          cocaine; or

(c)          marijuana.

Note:  amphetamines as specified is also defined in the Schedule 1 - Dictionary.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               VEA means the Veterans' Entitlements Act 1986.