Statement of Principles

concerning

TUBERCULOSIS
(Balance of Probabilities)

(No. 48 of 2024)

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

Dated 21 June 2024.

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

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 tuberculosis (Balance of Probabilities) (No. 48 of 2024).

2               Commencement

              This instrument commences on 23 July 2024.

3               Authority

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

4               Repeal

The Statement of Principles concerning tuberculosis No. 82 of 2015 (Federal Register of Legislation No. F2015L00914) made under subsection 196B(3) of the VEA is repealed.

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 tuberculosis and death from tuberculosis.

Meaning of tuberculosis

(2)          For the purposes of this Statement of Principles, tuberculosis:

(a)          means an infection caused by bacteria belonging to the Mycobacterium tuberculosis complex, including M. tuberculosis, M. africanum, M. canettii, M. caprae, M. microti, M. orygis, M. pinnipedi and M. bovis (including Bacille Calmette-Guérin); and

(b)          includes:

(i)            latent tuberculosis;

(ii)         pulmonary tuberculosis; and

(iii)       extrapulmonary tuberculosis; and

(c)          excludes infection caused by atypical mycobacteria such as M. avium, M. intracellulare, M. kansasii, M. marinum and M. ulcerans.

Note: The Mycobacterium tuberculosis complex is a genetically related group of Mycobacterium species that cause tuberculosis.

(3)          While tuberculosis attracts ICD 10 AM codes A15, A16, A17, A18 and A19, in applying this Statement of Principles the meaning of tuberculosis 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), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from tuberculosis

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

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 tuberculosis and death from tuberculosis can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are 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, tuberculosis or death from tuberculosis is connected with the circumstances of a person's relevant service:

(1)          being exposed to bacteria belonging to the Mycobacterium tuberculosis complex at least 14 days before the clinical onset of tuberculosis;

Note: being exposed to bacteria belonging to the Mycobacterium tuberculosis complex is defined in the Schedule 1 - Dictionary.

(2)          living or working in an area which has an incidence of tuberculosis of at least 50 cases per 100,000 of population per year, before the clinical onset of tuberculosis, provided that the individual had no negative test results for tuberculosis in any intervening period between living or working in the affected area and the onset of tuberculosis;

(3)          consuming unpasteurised milk, unpasteurised dairy products or uncooked meat from an animal infected with Mycobacterium bovis or Mycobacterium caprae at least 14 days before the clinical onset of tuberculosis; 

(4)          for active tuberculosis disease due to infection with Mycobacterium bovis BCG only:

(a)          having intravesical BCG therapy for malignant neoplasm of the bladder; or

(b)          being vaccinated with BCG vaccine;

before the clinical onset of tuberculosis;

Note: active tuberculosis disease and BCG are defined in the Schedule 1 - Dictionary.

(5)          inability to access appropriate tuberculosis vaccination in accordance with contemporary medical standards before the clinical onset of tuberculosis;

(6)          having a substantially compromised immune system due to:

(a)          chronic renal failure;

(b)          haematological malignancy;

(c)          infection with human immunodeficiency virus;

(d)          severe malnutrition;

(e)          solid organ, stem cell or bone marrow transplantation; or

(f)           taking an immunosuppressive drug;

at the time of the clinical worsening of tuberculosis;

Note: chronic renal failure and immunosuppressive drug and severe malnutrition are defined in the Schedule -1 Dictionary.

(7)          inhaling at least 1,000 micrograms of beclomethasone, or equivalent inhaled glucocorticoid daily for the 6 months, before the clinical worsening of tuberculosis, and where the treatment has ceased, the last inhaled glucocorticoid dose was taken within the 30 days before the clinical worsening of tuberculosis;

Note: equivalent inhaled glucocorticoid is defined in the Schedule 1 - Dictionary

(8)          having cirrhosis of the liver at the time of the clinical worsening of tuberculosis;

(9)          having diabetes mellitus at the time of the clinical worsening of tuberculosis;

(10)      inhaling respirable crystalline silica dust in an enclosed space:

(a)          for a cumulative period of at least 3,000 hours before the clinical worsening of tuberculosis; and

(b)          at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting;

before the clinical worsening of tuberculosis;

(11)      inhaling respirable crystalline silica dust in an open environment:

(a)          for a cumulative period of at least 6,000 hours before the clinical worsening of tuberculosis; and

(b)          at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting;

before the clinical worsening of tuberculosis;

(12)      for pulmonary tuberculosis only, smoking at least 1 cigarette per day, or the equivalent thereof in other tobacco products, for at least the 12 months before the clinical worsening of tuberculosis;

Note: pulmonary tuberculosis is defined in the Schedule 1- Dictionary.

(13)      consuming at least 40 grams of alcohol per day for at least the 12 months before the clinical worsening of tuberculosis;

(14)      having alcohol use disorder at the time of the clinical worsening of tuberculosis;

(15)      having hepatitis C infection at the time of the clinical worsening of tuberculosis;

(16)      inability to obtain appropriate clinical management for tuberculosis before the clinical worsening of tuberculosis.

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(6) to 9(16) apply only to material contribution to, or aggravation of, tuberculosis where the person's tuberculosis 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:

                               active tuberculosis disease means an illness in which tuberculosis bacteria are multiplying and inducing an inflammatory response.

                               being exposed to bacteria belonging to the Mycobacterium tuberculosis complex means:

(a)          inhaling droplet nuclei or aerosols contaminated with Mycobacterium tuberculosis complex;

(b)          being in the same living quarters or immediate work environment as a person with infectious tuberculosis;

(c)          handling body tissues, body fluids, biopsy specimens, sputum or other pathological material infected with Mycobacterium tuberculosis complex; or

(d)          having a tissue or solid organ transplant which is infected with Mycobacterium tuberculosis complex.

Note: infectious tuberculosis and droplet nuclei are defined in the Schedule 1 - Dictionary.

                             BCG means Bacille Calmette-Guérin.

                               Body Mass Index (BMI) means W/H2 and where:

(a)          W is the person's weight in kilograms; and

(b)          H is the person's height in metres.

                               chronic renal failure means:

(a)          having a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or

(b)          a need for renal replacement therapy (dialysis or transplantation) for treatment of complications of decreased glomerular filtration rate which would otherwise increase the risk of morbidity and mortality; or

(c)          undergoing chronic dialysis.

                               droplet nuclei means the dried residue formed by evaporation of droplets coughed or sneezed into the atmosphere or by aerosolisation of infective material.

                               equivalent inhaled glucocorticoid means:

(a)          4,000 micrograms of triamcinolone;

(b)          800 micrograms of budesonide;

(c)          500 micrograms of fluticasone; or

(d)          a therapeutically equivalent dose of another inhaled glucocorticoid.

                               immunosuppressive drug means:

(a)          corticosteroids other than inhaled or topical corticosteroids;

(b)          drugs used to prevent transplant rejection;

(c)          tumour necrosis factor-α inhibitors; or

(d)          chemotherapeutic agents used for the treatment of cancer.

                               infectious tuberculosis means active tuberculosis, as confirmed by laboratory, radiological or contact tracing evidence indicating transmission of the organism. Laboratory evidence includes being positive for tuberculosis organisms on sputum smear, sputum culture or bronchial washings, testing positive for tuberculosis-specific nucleic acid from sputum or bronchial washings.

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                               protein-calorie malnutrition means undernourishment due to inadequate intake, absorption or utilisation of protein or energy foods.

pulmonary tuberculosis means tuberculosis infection that occurs in the lung or respiratory tract.

                             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.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               severe malnutrition means having protein-calorie malnutrition associated with a body mass index (BMI) less than or equal to 18.5 kg/m2.

Note: Body Mass Index (BMI) and protein-calorie malnutrition are 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.

                             tuberculosis—see subsection 7(2).

                             VEA means the Veterans' Entitlements Act 1986.