Statement of Principles concerning BRONCHIECTASIS (Reasonable Hypothesis) (No. 30 of 2017) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 21 April 2017 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 bronchiectasis (Reasonable Hypothesis) (No. 30 of 2017). 2 Commencement This instrument commences on 22 May 2017. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Revocation The Statement of Principles concerning bronchiectasis No. 17 of 2009 made under subsection 196B(2) of the VEA is revoked. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 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 bronchiectasis and death from bronchiectasis. Meaning of bronchiectasis (2) For the purposes of this Statement of Principles, bronchiectasis means: (a) an acquired lung disease with permanent and irreversible, abnormal dilatation of bronchi and bronchioles; and (b) excludes congenital bronchiectasis, and bronchiectasis associated with cystic fibrosis, alpha-1-antitrypsin deficiency, common variable immune deficiency and other genetic disorders. Death from bronchiectasis (3) For the purposes of this Statement of Principles, bronchiectasis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's bronchiectasis. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that bronchiectasis and death from bronchiectasis can be related to relevant service rendered by veterans, members of Peacekeeping Forces, 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 as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting bronchiectasis or death from bronchiectasis with the circumstances of a person's relevant service: (1) having viral or bacterial pneumonia within the ten years before the clinical onset of bronchiectasis; (2) having pertussis within the ten years before the clinical onset of bronchiectasis; (3) having pulmonary tuberculosis or non-tuberculous mycobacterial infection of the lung, before the clinical onset of bronchiectasis; (4) having sarcoidosis of the lung before the clinical onset of bronchiectasis; (5) having bronchial obstruction before the clinical onset of bronchiectasis, where the bronchiectasis is distal to that obstruction; Note: bronchial obstruction is defined in the Schedule 1 - Dictionary. (6) inhaling vapours, gases or fumes of a chemical agent from the specified list of chemical agents: (a) resulting in signs and symptoms of severe acute lower respiratory damage requiring medical attention within 48 hours after exposure; and (b) the persistence of respiratory symptoms and signs for at least one week after exposure, within the five years before the clinical onset of bronchiectasis; Note: specified list of chemical agents is defined in the Schedule 1 - Dictionary. (7) having an occupational lung disease from the specified list of occupational lung diseases at the time of the clinical onset of bronchiectasis; Note: specified list of occupational lung diseases is defined in the Schedule 1 - Dictionary. (8) inhaling sulphur mustard (mustard gas) before the clinical onset of bronchiectasis; (9) having aspiration pneumonitis within the five years before the clinical onset of bronchiectasis; Note: aspiration pneumonitis is defined in the Schedule 1 - Dictionary. (10) having gastro-oesophageal reflux disease, with erosive oesophagitis or oesophageal stricture, within the two years before the clinical onset of bronchiectasis; (11) having allergic bronchopulmonary aspergillosis at the time of the clinical onset of bronchiectasis; Note: allergic bronchopulmonary aspergillosis is defined in the Schedule 1 - Dictionary. (12) undergoing solid organ or bone marrow transplantation before the clinical onset of bronchiectasis; (13) having fibrosis or fibrosing interstitial lung disease, involving the segment of the lung affected by bronchiectasis, before the clinical onset of bronchiectasis; (14) being exposed to arsenic as specified before the clinical onset of bronchiectasis; Note: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary. (15) having a disease from the specified list of connective tissue diseases at the time of the clinical onset of bronchiectasis; Note: specified list of connective tissue diseases is defined in the Schedule 1 - Dictionary. (16) being infected with human immunodeficiency virus before the clinical onset of bronchiectasis; (17) having a haematological malignancy at the time of the clinical onset of bronchiectasis; (18) being treated with an immunosuppressive drug within the five years before the clinical onset of bronchiectasis; Note: immunosuppressive drug is defined in the Schedule 1 - Dictionary. (19) being infected with human T-cell lymphotropic virus type 1 before the clinical onset of bronchiectasis; (20) having inflammatory bowel disease at the time of the clinical onset of bronchiectasis; (21) having severe and persistent asthma within the five years before the clinical onset of bronchiectasis; Note: severe and persistent asthma is defined in the Schedule 1 - Dictionary. (22) having chronic obstructive pulmonary disease at the time of the clinical onset of bronchiectasis; (23) having an episode of acute viral or bacterial lower respiratory tract infection requiring medical treatment, within the one year before the clinical worsening of bronchiectasis; (24) having pertussis within the ten years before the clinical worsening of bronchiectasis; (25) having pulmonary tuberculosis or non-tuberculous mycobacterial infection of the lung before the clinical worsening of bronchiectasis; (26) having sarcoidosis of the lung before the clinical worsening of bronchiectasis; (27) having bronchial obstruction before the clinical worsening of bronchiectasis, where the bronchiectasis is distal to that obstruction; Note: bronchial obstruction is defined in the Schedule 1 - Dictionary. (28) inhaling vapours, gases or fumes of a chemical agent from the specified list of chemical agents: (a) resulting in signs and symptoms of severe acute lower respiratory damage requiring medical attention within 48 hours after exposure; and (b) the persistence of respiratory symptoms and signs for at least one week after exposure, within the five years before the clinical worsening of bronchiectasis; Note: specified list of chemical agents is defined in the Schedule 1 - Dictionary. (29) having an occupational lung disease from the specified list of occupational lung diseases at the time of the clinical worsening of bronchiectasis; Note: specified list of occupational lung diseases is defined in the Schedule 1 - Dictionary. (30) inhaling sulphur mustard (mustard gas) before the clinical worsening of bronchiectasis; (31) having aspiration pneumonitis within the five years before the clinical worsening of bronchiectasis; Note: aspiration pneumonitis is defined in the Schedule 1 - Dictionary. (32) having gastro-oesophageal reflux disease, with erosive oesophagitis or oesophageal stricture, within the two years before the clinical worsening of bronchiectasis; (33) having allergic bronchopulmonary aspergillosis at the time of the clinical worsening of bronchiectasis; Note: allergic bronchopulmonary aspergillosis is defined in the Schedule 1 - Dictionary. (34) undergoing solid organ or bone marrow transplantation before the clinical worsening of bronchiectasis; (35) having fibrosis or fibrosing interstitial lung disease, involving the segment of the lung affected by bronchiectasis, before the clinical worsening of bronchiectasis; (36) being exposed to arsenic as specified before the clinical worsening of bronchiectasis; Note: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary. (37) having a disease from the specified list of connective tissue diseases at the time of the clinical worsening of bronchiectasis; Note: specified list of connective tissue diseases is defined in the Schedule 1 - Dictionary. (38) being infected with human immunodeficiency virus before the clinical worsening of bronchiectasis; (39) having a haematological malignancy at the time of the clinical worsening of bronchiectasis; (40) being treated with an immunosuppressive drug within the five years before the clinical worsening of bronchiectasis; Note: immunosuppressive drug is defined in the Schedule 1 - Dictionary. (41) being infected with human T-cell lymphotropic virus type 1 before the clinical worsening of bronchiectasis; (42) having inflammatory bowel disease at the time of the clinical worsening of bronchiectasis; (43) having severe and persistent asthma within the five years before the clinical worsening of bronchiectasis; Note: severe and persistent asthma is defined in the Schedule 1 - Dictionary. (44) having chronic obstructive pulmonary disease at the time of the clinical worsening of bronchiectasis; (45) inability to obtain appropriate clinical management for bronchiectasis. 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(23) to 9(45) apply only to material contribution to, or aggravation of, bronchiectasis where the person's bronchiectasis 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(2) 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: allergic bronchopulmonary aspergillosis means infection of the bronchi and lungs by species of Aspergillus accompanied by wheeze, often with expectoration of yellow or brown bronchial plugs composed of eosinophils and fungal hyphae. aspiration pneumonitis means inflammation of the lungs with clinical or radiological evidence of consolidation due to the deposition into the respiratory tract of a substance or material from the upper aerodigestive tract. Note: Examples of a substance or material that may be deposited from the upper aerodigestive tract include food particles, oral secretions or gastric contents. being exposed to arsenic as specified means: (a) consuming drinking water with an average arsenic concentration of at least 50 micrograms per litre for a cumulative period of at least ten years; or (b) having clinical evidence of excessive chronic arsenic exposure. bronchial obstruction means partial or complete blockage of the lumen of a bronchus. Note: Examples of a cause of bronchial obstruction include an inhaled foreign body, broncholith or neoplasm, extrinsic narrowing due to enlarged lymph nodes, twisting or displacement of the airways after a lobar resection, or middle lobe syndrome. bronchiectasis—see subsection 7(2). immunosuppressive drug means a drug or an agent which results in substantial suppression of immune responses. Note: Examples of an immunosuppressive drug include corticosteroids other than inhaled or topical corticosteroids, drugs used to prevent transplant rejection, tumour necrosis factor-α inhibitors and chemotherapeutic agents used for the treatment of cancer. MRCA means the Military Rehabilitation and Compensation Act 2004. relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. severe and persistent asthma means asthma having any of the following specified characteristics, alone or in combination, for a cumulative period of at least six months within a continuous one year period: (a) FEV1 (forced expiratory volume in one second) of 60% or less of expected value; (b) wheeze, tightness, cough, dyspnoea or other symptoms occurring throughout each day; (c) frequent flare-ups; (d) the presence of night-time symptoms on more than one night per week; or (e) symptoms frequently restrict activity or sleep. specified list of chemical agents means: (a) ammonia; (b) chlorine; (c) oxides of nitrogen; (d) oxides of sulphur; (e) paraquat; (f) phosgene; or (g) smoke from fires. specified list of connective tissue diseases means: (a) ankylosing spondylitis; (b) dermatomyositis; (c) eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome); (d) granulomatosis with polyangiitis (Wegener's granulomatosis); (e) microscopic polyangiitis; (f) mixed connective tissue disease; (g) polymyositis; (h) relapsing polychondritis; (i) rheumatoid arthritis; (j) Sjogren's syndrome; (k) systemic lupus erythematosus; (l) systemic sclerosis; or (m) Takayasu arteritis. specified list of occupational lung diseases means: (a) asbestosis; (b) byssinosis; (c) coal worker's pneumoconiosis; (d) extrinsic allergic alveolitis; (e) flavour worker's lung; (f) hard metal pneumoconiosis; or (g) silicosis. 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.