Statement of Principles concerning rheumatoid arthritis (Reasonable Hypothesis) (No. 50 of 2017) (Cth)

Statement of Principles

concerning

RHEUMATOID ARTHRITIS
(Reasonable Hypothesis)

(No. 50 of 2017)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated    18 August 2017

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

Professor Nicholas Saunders AO
Chairperson

Contents

1Name........................................................................................................................................... 3

2Commencement........................................................................................................................ 3

3Authority..................................................................................................................................... 3

4Revocation................................................................................................................................. 3

5Application................................................................................................................................. 3

6Definitions.................................................................................................................................. 3

7Kind of injury, disease or death to which this Statement of Principles relates............... 3

8Basis for determining the factors........................................................................................... 4

9Factors that must exist............................................................................................................. 4

10Relationship to service............................................................................................................. 6

11Factors referring to an injury or disease covered by another Statement of Principles. 6

Schedule 1 - Dictionary............................................................................................. 7

1Definitions.................................................................................................................................. 7

1. Name

This is the Statement of Principles concerning rheumatoid arthritis (Reasonable Hypothesis) (No. 50 of 2017).

1. Commencement

This instrument commences on 18 September 2017.

1. Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

1. Revocation

The Statement of Principles concerning rheumatoid arthritis No. 68 of 2008 made under subsection 196B(2) of the VEA is revoked.

1. 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.

1. Definitions

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

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

(1)This Statement of Principles is about rheumatoid arthritis and death from rheumatoid arthritis.

Meaning of rheumatoid arthritis

(2)For the purposes of this Statement of Principles, rheumatoid arthritis means:

(a)a symmetric, inflammatory, peripheral polyarthritis persisting for a continuous period of at least six weeks, characterised by inflammatory synovitis; and

(b)excludes juvenile rheumatoid arthritis and non-rheumatoid conditions that may have similar clinical features, such as psoriatic arthritis, acute viral polyarthritis, systemic lupus erythematosus and polyarticular gout.

Note: Rheumatoid arthritis usually involves peripheral joints, including cartilage damage and bone erosions and changes in joint integrity as manifestations of established disease.  In addition, extra-articular manifestations are common.

(3)While rheumatoid arthritis attracts ICD‑10‑AM code M05 or M06, in applying this Statement of Principles the meaning of rheumatoid arthritis 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 rheumatoid arthritis

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

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

1. Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that rheumatoid arthritis and death from rheumatoid arthritis 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.

1. 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 rheumatoid arthritis or death from rheumatoid arthritis with the circumstances of a person's relevant service:

(1)smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of rheumatoid arthritis, and where smoking has ceased, the clinical onset of rheumatoid arthritis has occurred within 20 years of cessation;

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

(2)inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being:

(a)produced;

(b)excavated;

(c)drilled, cut or ground; or

(d)used in construction, manufacturing, cleaning or blasting;

for a cumulative period of at least 2 500 hours within a continuous period of ten years, before the clinical onset of rheumatoid arthritis;

(3)being treated with a drug from Specified List 1 of drugs within the eight weeks before the clinical onset of rheumatoid arthritis;

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

(4)having periodontitis for at least the three months before the clinical onset of rheumatoid arthritis;

(5)being obese for at least five years within the ten years before the clinical onset of rheumatoid arthritis;

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

(6)consuming an average of at least 400 millilitres per day of beverages sweetened with high fructose corn syrup, for a period of at least one year within the five years before the clinical onset of rheumatoid arthritis;

(7)having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre, for a continuous period of at least one year within the ten years before the clinical onset of rheumatoid arthritis;

(8)smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of rheumatoid arthritis, and where smoking has ceased, the clinical worsening of rheumatoid arthritis has occurred within five years of cessation;

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

(9)inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being:

(a)produced;

(b)excavated;

(c)drilled, cut or ground; or

(d)used in construction, manufacturing, cleaning or blasting;

for a cumulative period of at least 2 500 hours within a continuous period of ten years, before the clinical worsening of rheumatoid arthritis;

(10)being treated with a drug from Specified List 2 of drugs within the eight weeks before the clinical worsening of rheumatoid arthritis;

Note: Specified List 2 of drugs is defined in the Schedule 1 - Dictionary.

(11)suddenly discontinuing treatment with a disease modifying antirheumatic drug after undergoing continuous disease modifying antirheumatic drug treatment for at least six months, within the six months before the clinical worsening of rheumatoid arthritis;

Note: disease modifying antirheumatic drug is defined in the Schedule 1 - Dictionary.

(12)having periodontitis for at least the three months before the clinical worsening of rheumatoid arthritis;

(13)being obese for at least five years within the ten years before the clinical worsening of rheumatoid arthritis;

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

(14)consuming an average of at least 400 millilitres per day of beverages sweetened with high fructose corn syrup, for a period of at least one year within the five years before the clinical worsening of rheumatoid arthritis;

(15)having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre, for a continuous period of at least one year within the ten years before the clinical worsening of rheumatoid arthritis;

(16)inability to obtain appropriate clinical management for rheumatoid arthritis.

1. 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(8) to 9(16) apply only to material contribution to, or aggravation of, rheumatoid arthritis where the person's rheumatoid arthritis was suffered or contracted before or during (but did not arise out of) the person's relevant service.

1. 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:

being obese means having a Body Mass Index (BMI) of 30 or greater.

BMI means W/H² where:

W is the person's weight in kilograms; and

H is the person's height in metres.

disease modifying antirheumatic drug means a pharmacological agent which reduces or eradicates synovial inflammation, including methotrexate, prednisone, hydroxychloroquine, sulfasalazine, leflunomide, cyclosporine, abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, tocilizumab and rituximab.

MRCAmeans the Military Rehabilitation and Compensation Act 2004.

pack-years 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)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.

rheumatoid arthritis—see subsection 7(2).

Specified List 1 of drugs means:

(a)granulocyte colony-stimulating factors (G-CSF);

(b)granulocyte-macrophage colony-stimulating factors (GM-CSF);

(c)interferon-α;

(d)interleukin 2; or

(e)intradermal or intravesical bacillus Calmette-Guérin (BCG).

Specified List 2 of drugs means:

(a)arsenic trioxide;

(b)granulocyte colony-stimulating factors (G-CSF);

(c)granulocyte-macrophage colony-stimulating factors (GM-CSF);

(d)interferon-α;

(e)interleukin 2;

(f)intradermal or intravesical bacillus Calmette-Guérin (BCG); or

(g)intravenous iron dextran.

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.