Statement of Principles
concerning
FIBROSING INTERSTITIAL LUNG DISEASE
No. 36 of 2009
for the purposes of the
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
Title
1. This Instrument may be cited as Statement of Principles concerning fibrosing interstitial lung disease No. 36 of 2009.
Determination
2. The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a) revokes Instrument No. 16 of 1998 concerning idiopathic fibrosing alveolitis; and
(b) determines in its place this Statement of Principles.
Kind of injury, disease or death
3. (a) This Statement of Principles is about fibrosing interstitial lung disease and death from fibrosing interstitial lung disease.
(b) For the purposes of this Statement of Principles, "fibrosing interstitial lung disease" means one of a diverse group of lung diseases that are characterized by chronic inflammation and progressive fibrosis of the pulmonary interstitium. This definition excludes asbestosis, extrinsic allergic alveolitis, organising pneumonia, desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, and pulmonary manifestations of systemic diseases.
Basis for determining the factors
4. On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that fibrosing interstitial lung disease and death from fibrosing interstitial lung disease can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
Factors that must be related to service
5. Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
Factors
6. The factor that must exist before it can be said that, on the balance of probabilities, fibrosing interstitial lung disease or death from fibrosing interstitial lung disease is connected with the circumstances of a person’s relevant service is:
(a) inhaling beryllium dust or fumes before the clinical onset of fibrosing interstitial lung disease; or
(b) inhaling respirable crystalline silica dust in an enclosed space at the time material containing crystalline silica was being:
(i) produced;
(ii) excavated;
(iii) drilled, cut or ground, or
(iv) used in construction, manufacturing, cleaning or blasting,
for a cumulative period of at least 3000 hours, and the first inhalation of respirable crystalline silica dust occurred at least ten years before the clinical onset of fibrosing interstitial lung disease; or
(c) inhaling respirable crystalline silica dust in an open environment at the time material containing crystalline silica was being:
(i) produced;
(ii) excavated;
(iii) drilled, cut or ground, or
(iv) used in construction, manufacturing, cleaning or blasting,
for a cumulative period of at least 6000 hours, and the first inhalation of respirable crystalline silica dust occurred at least ten years before the clinical onset of fibrosing interstitial lung disease; or
(d) having acute silicosis within the three months before the clinical onset of fibrosing interstitial lung disease; or
(e) receiving an intravenous injection of a talc-containing drug intended for oral use, on more days than not, for a period of at least three years, within the ten years before the clinical onset of fibrosing interstitial lung disease; or
(f) inhaling respirable coal dust in an enclosed space for a cumulative period of at least 6000 hours, and the first inhalation of respirable coal dust occurred at least ten years before the clinical onset of fibrosing interstitial lung disease; or
(g) inhaling respirable dust generated from hard metal or diamond-cobalt, while engaged in the manufacture, utilisation, or maintenance of tools composed of hard metal or diamond-cobalt, for a cumulative period of at least 720 hours before the clinical onset of fibrosing interstitial lung disease; or
(h) inhaling toxic gases or fumes within the 12 months before the clinical onset of fibrosing interstitial lung disease; or
(i) having paraquat poisoning within the three months before the clinical onset of fibrosing interstitial lung disease; or
(j) inhaling mustard gas within the 20 years before the clinical onset of fibrosing interstitial lung disease; or
(k) undergoing a course of therapeutic radiation to the region of the chest before the clinical onset of fibrosing interstitial lung disease; or
(l) having received a cumulative equivalent dose of at least 0.4 Sievert of atomic radiation to the lung, before the clinical onset of fibrosing interstitial lung disease; or
(m) having received a cumulative dose of at least 0.4 Sievert of ionising radiation to the lung, from internal deposition of a substance which emits alpha particles, before the clinical onset of fibrosing interstitial lung disease; or
(n) having received 131Iodine as therapy for widespread pulmonary metastases from a malignant neoplasm of the thyroid, before the clinical onset of fibrosing interstitial lung disease; or
(o) having received 90Yttrium microspheres as therapy for primary and metastatic liver tumours, before the clinical onset of fibrosing interstitial lung disease; or
(p) having acute respiratory distress syndrome within the six months before the clinical onset of fibrosing interstitial lung disease; or
(q) being treated with a cytotoxic agent for a malignant disease or in association with haematopoietic stem cell transplantation, before the clinical onset of fibrosing interstitial lung disease; or
(r) being treated with a drug from the specified list within the six months before the clinical onset of fibrosing interstitial lung disease; or
(s) having chronic or recurrent diffuse alveolar haemorrhage before the clinical onset of fibrosing interstitial lung disease; or
(t) having exogenous lipoid pneumonitis at the time of the clinical onset of fibrosing interstitial lung disease; or
(u) having tropical pulmonary eosinophilia for at least the six months before the clinical onset of fibrosing interstitial lung disease; or
(v) inhaling beryllium dust or fumes before the clinical worsening of fibrosing interstitial lung disease; or
(w) inhaling respirable crystalline silica dust in an enclosed space at the time material containing crystalline silica was being:
(i) produced;
(ii) excavated;
(iii) drilled, cut or ground, or
(iv) used in construction, manufacturing, cleaning or blasting,
for a cumulative period of at least 3000 hours, and the first inhalation of respirable crystalline silica dust occurred at least ten years before the clinical worsening of fibrosing interstitial lung disease; or
(x) inhaling respirable crystalline silica dust in an open environment at the time material containing crystalline silica was being:
(i) produced;
(ii) excavated;
(iii) drilled, cut or ground, or
(iv) used in construction, manufacturing, cleaning or blasting,
for a cumulative period of at least 6000 hours, and the first inhalation of respirable crystalline silica dust occurred at least ten years before the clinical worsening of fibrosing interstitial lung disease; or
(y) having acute silicosis within the three months before the clinical worsening of fibrosing interstitial lung disease; or
(z) receiving an intravenous injection of a talc-containing drug intended for oral use, on more days than not, for a period of at least three years, within the ten years before the clinical worsening of fibrosing interstitial lung disease; or
(aa) inhaling respirable coal dust in an enclosed space for a cumulative period of at least 6000 hours, and the first inhalation of respirable coal dust occurred at least ten years before the clinical worsening of fibrosing interstitial lung disease; or
(bb) inhaling respirable dust generated from hard metal or diamond-cobalt, while engaged in the manufacture, utilisation, or maintenance of tools composed of hard metal or diamond-cobalt, for a cumulative period of at least 720 hours before the clinical worsening of fibrosing interstitial lung disease; or
(cc) inhaling toxic gases or fumes within the 12 months before the clinical worsening of fibrosing interstitial lung disease; or
(dd) having paraquat poisoning within the six months before the clinical worsening of fibrosing interstitial lung disease; or
(ee) inhaling mustard gas within the 20 years before the clinical worsening of fibrosing interstitial lung disease; or
(ff) undergoing a course of therapeutic radiation to the region of the chest before the clinical worsening of fibrosing interstitial lung disease; or
(gg) having received a cumulative equivalent dose of at least 0.4 Sievert of atomic radiation to the lung, before the clinical worsening of fibrosing interstitial lung disease; or
(hh) having received a cumulative dose of at least 0.4 Sievert of ionising radiation to the lung, from internal deposition of a substance which emits alpha particles, before the clinical worsening of fibrosing interstitial lung disease; or
(ii) having received 131Iodine as therapy for widespread pulmonary metastases from a malignant neoplasm of the thyroid, before the clinical worsening of fibrosing interstitial lung disease; or
(jj) having received 90Yttrium microspheres as therapy for primary and metastatic liver tumours, before the clinical worsening of fibrosing interstitial lung disease; or
(kk) having acute respiratory distress syndrome within the six months before the clinical worsening of fibrosing interstitial lung disease; or
(ll) being treated with a cytotoxic agent for a malignant disease or in association with haematopoietic stem cell transplantation, before the clinical worsening of fibrosing interstitial lung disease; or
(mm) being treated with a drug from the specified list within the six months before the clinical worsening of fibrosing interstitial lung disease; or
(nn) having chronic or recurrent diffuse alveolar haemorrhage before the clinical worsening of fibrosing interstitial lung disease; or
(oo) having exogenous lipoid pneumonitis at the time of the clinical worsening of fibrosing interstitial lung disease; or
(pp) having tropical pulmonary eosinophilia for at least the six months before the clinical worsening of fibrosing interstitial lung disease; or
(qq) inability to obtain appropriate clinical management for fibrosing interstitial lung disease.
Factors that apply only to material contribution or aggravation
7. Paragraphs 6(v) to 6(qq) apply only to material contribution to, or aggravation of, fibrosing interstitial lung disease where the person’s fibrosing interstitial lung disease was suffered or contracted before or during (but not arising out of) the person’s relevant service.
Inclusion of Statements of Principles
8. In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
Other definitions
9. For the purposes of this Statement of Principles:
"a course of therapeutic radiation" means one or more fractions (treatment portions) of ionising radiation administered with the aim of achieving palliation or cure with gamma rays, x-rays, alpha particles or beta particles;
"a drug from the specified list" means:
(a) amiodarone;
(b) azathioprine;
(c) D-penicillamine;
(d) erlotinib;
(e) gefitinib;
(f) gold salts;
(g) methotrexate;
(h) mycophenolate mofetil;
(i) nitrofurantoin;
(j) sirolimus
(k) sulphasalazine; or
(l) tocainide;
"acute respiratory distress syndrome" means a clinical syndrome of severe dyspnoea of rapid onset, hypoxaemia, and diffuse pulmonary infiltrates leading to respiratory failure;
"acute silicosis" means a pulmonary disease characterised by basilar filling of alveoli with lipid and proteinaceous exudative material, following exposure to excessive levels of respirable crystalline silica dust over a short time span;
"atomic radiation" means ionising radiation excluding:
(a) natural background radiation;
(b) therapeutic radiation; and
(c) radiation from diagnostic procedures;
"cumulative equivalent dose" means the total equivalent dose of radiation from all types of ionising radiation. It accounts for the differences in biological effectiveness of various types of radiation and allows doses from different radiations to be combined. Each component is calculated by multiplying the absorbed dose in a particular tissue or organ for a given type of radiation by the radiation weighting factor for that radiation. The unit of equivalent dose is the Sievert;
"death from fibrosing interstitial lung disease" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s fibrosing interstitial lung disease;
"diffuse alveolar haemorrhage" means extravasation of blood into the alveoli and interstitium from injury to the pulmonary microcirculation;
"exogenous lipoid pneumonitis" means inflammation of the pulmonary interstitium due to the aspiration or inhalation of oil-based substances;
"hard metal" means material composed predominantly of cobalt and tungsten carbide;
"inhaling beryllium dust or fumes" means having a history of exposure to beryllium dust or beryllium fumes, for a cumulative period of at least 480 hours or clinical evidence of sensitisation to beryllium by positive findings on beryllium lymphocyte proliferation testing of blood or bronchoalveolar lavage fluid;
"inhaling toxic gases or fumes" means inhaling toxic agents, including anhydrous ammonia fumes, smoke, oxides of sulphur, oxides of nitrogen, chlorine or phosgene, with development of inflammation of the pulmonary interstitium;
"paraquat" is a dipyridilium compound whose dichloride and dimethylsulphate salts are used as contact herbicides;
"relevant service" means:
(a) eligible war service (other than operational service) under the VEA; or
(b) defence service (other than hazardous service) under the VEA; or
(c) peacetime service under the MRCA;
"terminal event" means the proximate or ultimate cause of death and includes:
(a) pneumonia;
(b) respiratory failure;
(c) cardiac arrest;
(d) circulatory failure; or
(e) cessation of brain function;
"tropical pulmonary eosinophilia" means a disorder which is characterised by pulmonary infiltrations of eosinophils and blood eosinophilia, and is caused by infection with the microfilariae Wuchereria bancrofti or Brugia malayi.
Application
10. This Instrument applies to all matters to which section 120B of the VEA or section 339 of the MRCA applies.
Date of effect
11. This Instrument takes effect from 6 May 2009.
Dated this twenty-fourth day of April 2009
The Common Seal of the )
Repatriation Medical Authority )
was affixed to this instrument )
in the presence of: )
KEN DONALD
CHAIRPERSON
