COVID-19 — DVA claim example

Diagnostic Assessment — COVID-19

Example 1 of 1 · fictitious patient (Veteran DO)

Diagnostic Assessment

COVID-19

BOP Code: 47 of 2020 (Coronavirus Disease 2019 (COVID-19))
RH Code: 46 of 2020 (Coronavirus Disease 2019 (COVID-19))

ADF History

Veteran DO, date of birth 19 October 1986, Australian Army, Communications Systems Operator (Royal Australian Corps of Signals), enlisted 07 March 2005, medically discharged 12 July 2024. Operational service: Afghanistan, 02 April 2012 to 30 November 2012 (warlike); Middle East Area of Operations, 15 November 2021 to 25 February 2022 (warlike, repatriated early on medical grounds).

Occupational History

As a communications systems operator the veteran installed, operated and maintained radio, satellite and network systems, usually in crowded, enclosed and air-conditioned operations rooms and communications shelters staffed around the clock. Operators share headsets, keyboards, handsets and workstations across shifts, and work in close proximity for long hours, conditions that favour the spread of respiratory infections.

On operations, personnel live in shared accommodation and eat in communal dining facilities, travel in crowded transport and work alongside coalition partners and local staff. During the COVID-19 pandemic deployed bases experienced outbreaks that were difficult to contain, and specialist treatment, antiviral medication and timely evacuation were constrained by distance, operational demands and pandemic transport restrictions.

During the pandemic, deployed personnel were required to continue essential communications duties throughout outbreaks, because operations rooms could not be closed or staffed remotely. Rotation of staff between shifts and shared equipment meant that an infection in one operator quickly exposed the whole team.

History

Veteran DO, a communications systems operator in the Australian Army, developed COVID-19 on 31 January 2022 during warlike service in the Middle East Area of Operations, after his room-mate and two operations room colleagues tested positive during an outbreak on the base. The infection was confirmed by PCR on the day of onset, progressed to COVID-19 pneumonia requiring oxygen and was complicated by delayed access to antiviral treatment and evacuation, and he was repatriated early with persisting post-COVID symptoms.

Timeline

• 14 Oct 2021 — Pre-deployment medical examination found the veteran fit for deployment, with normal respiratory examination, oxygen saturation of 99 per cent on air and normal spirometry. He had received two doses of an mRNA COVID-19 vaccine in June and July 2021. A booster dose was not yet available to him before departure. He had no previous COVID-19 infection. "fit to deploy, two vaccine doses"
• 28 Jan 2022 — During warlike service in the Middle East Area of Operations an outbreak of COVID-19 was declared on the base, with 14 confirmed cases by 30 January 2022 during the regional Omicron wave. The veteran's room-mate, with whom he shared a two-person accommodation unit, tested positive by PCR on 28 January 2022, as did two operators on his shift in the communications operations room, where he had worked beside them at shared workstations for twelve-hour shifts from 19 to 27 January 2022. He was placed in close-contact quarantine. "room-mate and shift colleagues positive"
• 31 Jan 2022 — He developed fever of 38.6 degrees, chills, sore throat, dry cough, headache, myalgia and loss of taste and smell. A rapid antigen test and nasopharyngeal PCR were positive for SARS-CoV-2 the same day. The role 1 medical officer confirmed COVID-19 and isolated him in quarantine accommodation with daily review. "SARS-CoV-2 PCR positive, febrile"
• 06 Feb 2022 — On day seven of illness he became increasingly breathless, with oxygen saturation of 89 per cent on air, respiratory rate 28 and widespread crackles. Chest X-ray showed bilateral patchy infiltrates. COVID-19 pneumonia was diagnosed and he was given supplemental oxygen and dexamethasone 6 mg daily. Antiviral treatment was not available at the role 1 facility, and aeromedical transfer was delayed for four days by pandemic restrictions on patient transport. "COVID pneumonia, SpO2 89 per cent"
• 10 Feb 2022 — He was transferred to a coalition role 3 hospital in theatre, where he required high-flow nasal oxygen for three days and therapeutic anticoagulation for a raised D-dimer. CT of the chest on 14 February 2022 showed extensive bilateral ground-glass opacities without pulmonary embolism. He improved slowly and was weaned to room air on 18 February 2022. "high-flow oxygen, role 3 hospital"
• 25 Feb 2022 — He was aeromedically repatriated to Australia because of persisting breathlessness and fatigue and was admitted to a military health facility for convalescence. Oxygen saturation fell to 92 per cent on walking. He was placed on restricted duties. "repatriated, exertional desaturation"
• 18 Aug 2022 — A respiratory physician reviewed him for persisting breathlessness on exertion, fatigue, chest tightness and poor concentration six months after infection. Lung function testing showed a gas transfer of 68 per cent predicted and the six-minute walk distance was reduced. Follow-up CT showed residual subpleural bands. Post-COVID-19 condition following COVID-19 pneumonia was diagnosed. "post-COVID, DLCO 68 per cent"
• 14 Mar 2023 — At a further respiratory review thirteen months after infection the veteran still reported breathlessness on exertion, fatigue and cognitive slowing that prevented him from completing shift work in the communications operations room. Repeat lung function showed gas transfer of 74 per cent predicted, and a cardiopulmonary exercise test showed reduced exercise capacity without a cardiac cause. A medical employment classification review began, leading to his medical discharge. "persisting post-COVID limitation"

Symptoms

At onset the veteran had fever, chills, sore throat, dry cough, headache, generalised muscle aches and loss of taste and smell. From day seven of the illness he developed progressive breathlessness and low oxygen levels from COVID-19 pneumonia, requiring oxygen and hospital care.

He now reports breathlessness on climbing stairs or walking briskly, fatigue that limits his work and exercise, chest tightness, poor concentration and memory, and an altered sense of smell. He has not returned to his previous level of fitness.

His partner reports that he sleeps for long periods after minor exertion, has lost interest in sport and becomes frustrated by forgetfulness at work. He uses a reliever inhaler on exertion and has completed a pulmonary rehabilitation program with partial improvement.

Imaging

• 06 Feb 2022 — Chest X-ray: "Bilateral patchy peripheral airspace opacities in the mid and lower zones, consistent with viral pneumonia. No pleural effusion."
• 14 Feb 2022 — CT pulmonary angiogram: "Extensive bilateral peripheral and basal ground-glass opacities with areas of consolidation, consistent with COVID-19 pneumonia. No pulmonary embolism."
• 18 Aug 2022 — High-resolution CT chest: "Marked improvement. Residual subpleural curvilinear bands and minor reticulation in both lower lobes, consistent with post-COVID-19 change. No progressive fibrosis."

Onset Date

The most likely date of onset of this condition is 31 Jan 2022.

At that date the veteran was on warlike service in the Middle East Area of Operations, working twelve-hour shifts in a crowded communications operations room and sharing a two-person accommodation unit. An outbreak of COVID-19 had been declared on the base, and he was in close-contact quarantine after his room-mate and two shift colleagues tested positive.

This date is appropriate because he was well and fit for duty, with no respiratory symptoms, up to and including his shift on 27 January 2022 and his quarantine health check on 30 January 2022, and on 31 January 2022 he developed fever, cough and loss of taste and smell, with a positive PCR the same day. It falls within uninterrupted full-time service and within his warlike deployment.

For the exposure factor, the 14 days before onset run from 17 Jan 2022 to 31 Jan 2022. Throughout that window he was in a country with current SARS-CoV-2 transmission; he shared his accommodation with his room-mate, who tested positive on 28 Jan 2022; he worked within two metres of two infected colleagues at shared workstations from 19 to 27 Jan 2022, handling their headsets and keyboards; and he breathed recirculated air in the enclosed operations room during the outbreak.

The clinical management factor relates to the period after onset, from 31 Jan 2022, and in particular to the deterioration on 06 Feb 2022, when antiviral treatment was unavailable and evacuation was delayed for four days, to his transfer on 10 Feb 2022.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Coronavirus Disease 2019 (COVID-19) (ICD-10-AM U07.1), virus identified, complicated by COVID-19 pneumonia and followed by post-COVID-19 condition, under the Statements of Principles concerning coronavirus disease 2019 (COVID-19), Balance of Probabilities No. 47 of 2020 and Reasonable Hypothesis No. 46 of 2020.

COVID-19 is an illness caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spread mainly by respiratory droplets and aerosols from infected people, particularly in crowded, enclosed and poorly ventilated spaces, and less often by contaminated surfaces. Typical features are fever, chills, cough, sore throat, headache, muscle pain, fatigue, breathlessness and loss of taste and smell. In some people the infection progresses to viral pneumonia with low oxygen levels, blood clotting complications and respiratory failure. A proportion of people have persisting symptoms for months afterwards, including fatigue, breathlessness and cognitive difficulties.

The diagnosis followed close exposure to infected room-mates and colleagues during an outbreak on a deployed base. It began on 31 January 2022, was confirmed by PCR the same day and progressed to pneumonia requiring oxygen.

COVID-19 pneumonia is distinguished from a mild infection by low oxygen levels and lung changes on imaging. Recovery after pneumonia is often slow, and persisting reductions in gas transfer and exercise capacity, as found in this veteran, are recognised consequences of more severe infection.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

31 January 2022.

When did the veteran first present to a health / medical provider for this condition?

31 January 2022.

When was the condition confirmed / formally diagnosed?

31 January 2022.

When did the veteran first present to you (or your practice) for this condition?

11 September 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by a nasopharyngeal PCR test positive for SARS-CoV-2 on 31 January 2022, together with a positive rapid antigen test and a typical illness of fever, cough, sore throat, myalgia and new loss of taste and smell. This meets the Statement of Principles definition of coronavirus disease 2019 (COVID-19) as an illness caused by infection with SARS-CoV-2.

The progression to COVID-19 pneumonia was confirmed by hypoxia, bilateral infiltrates on chest X-ray on 06 February 2022 and bilateral ground-glass opacities on CT on 14 February 2022, and the role 3 hospital physicians confirmed the diagnosis. A respiratory physician confirmed post-COVID-19 condition on 18 August 2022, with reduced gas transfer and residual changes on CT.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 31 January 2022, after 1 July 2004, during continuous full-time service and on warlike service in the Middle East Area of Operations. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to his warlike service, where the exposure and infection occurred. The Balance of Probabilities instrument applies to peacetime service and, as the exposure arose directly from his duties and the living arrangements imposed by service, it is also satisfied on the same facts.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Coronavirus Disease 2019 (COVID-19), No. 47 of 2020

Causative factors

Factor 8(1): being exposed to SARS-CoV-2 as specified within the 14 days before the clinical onset of coronavirus disease 2019 (COVID-19); — MET

- Within the 14 days before onset, from 17 January 2022 to 31 January 2022, the veteran was exposed to SARS-CoV-2 in each of the specified ways. He was in an area experiencing current transmission, with an outbreak of 14 cases declared on his base. He shared his accommodation unit with his room-mate, who tested positive on 28 January 2022. He worked within two metres of two colleagues who tested positive, sharing their workstations, headsets and keyboards, from 19 to 27 January 2022, and breathed recirculated air in the enclosed operations room. Every one of these exposures arose from the accommodation and duties required by his service, and he became unwell three days after his room-mate's positive test, within the usual incubation period.

Worsening factors

Factor 8(2): inability to obtain appropriate clinical management for coronavirus disease 2019 (COVID-19). — MET

- When the veteran developed hypoxic COVID-19 pneumonia on 06 February 2022, oral antiviral treatment was not available at the role 1 facility, and transfer to hospital care was delayed for four days by restrictions on moving COVID-19 positive patients. He deteriorated during that delay and required high-flow oxygen on arrival at the role 3 hospital on 10 February 2022. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Coronavirus Disease 2019 (COVID-19), No. 46 of 2020

Causative factors

Factor 8(1): being exposed to SARS-CoV-2 as specified within the 14 days before the clinical onset of coronavirus disease 2019 (COVID-19); — MET

- On warlike service in the Middle East Area of Operations, within the 14 days before onset, from 17 January 2022 to 31 January 2022, the veteran was in an area with current SARS-CoV-2 transmission during the regional Omicron wave; shared a two-person accommodation unit with a room-mate who tested positive on 28 January 2022; had direct contact with headsets, keyboards and handsets used by infected colleagues; worked within two metres of two infected operators for twelve-hour shifts from 19 to 27 January 2022; and inhaled aerosols in an enclosed, recirculated-air operations room during a declared outbreak. All of these exposures arose from his warlike deployment.

Worsening factors

Factor 8(2): inability to obtain appropriate clinical management for coronavirus disease 2019 (COVID-19). — MET

- On warlike service, no antiviral therapy was available at the deployed role 1 facility when his illness progressed to pneumonia on 06 February 2022, and his aeromedical transfer was delayed for four days by pandemic transport restrictions and the operational tempo. He needed high-flow oxygen when he reached the role 3 hospital on 10 February 2022. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

The COVID-19 was complicated by COVID-19 pneumonia and has been followed by post-COVID-19 condition, with persisting breathlessness, reduced gas transfer, residual lung changes, fatigue and cognitive difficulties. These sequelae led to his medical downgrading and contributed to his medical discharge on 12 July 2024.

Unintended Consequence

Not met as a cause of the infection itself. The dexamethasone and anticoagulation provided by the Commonwealth on deployment were appropriate treatment and are not identified as causing the condition, although the unavailability of antiviral treatment is addressed below.

Inability to Attain Appropriate Medical Management

MET. When the infection progressed to hypoxic pneumonia on 06 February 2022, antiviral treatment was not available at the role 1 facility and his transfer to hospital care was delayed for four days by pandemic restrictions on moving infected patients and by operational demands. He deteriorated during the delay and required high-flow nasal oxygen when he reached the role 3 hospital. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational and pandemic constraints that prevent timely access to effective treatment amount to an inability to obtain appropriate clinical management. The unavailability of a vaccine booster dose before his deployment is also indicative of barriers to care.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 14 Oct 2021, Pre-deployment medical examination, Medical Officer
2. 28 Jan 2022, Outbreak notification and contact tracing record, Deployed preventive medicine officer, Middle East Area of Operations
3. 31 Jan 2022, Deployed health record and SARS-CoV-2 PCR report, Medical Officer, role 1 facility
4. 06 Feb 2022, Deployed health record and chest X-ray report, Medical Officer, role 1 facility
5. 10 Feb 2022, Admission and discharge summary, Coalition role 3 hospital
6. 14 Feb 2022, CT pulmonary angiogram report, Radiologist
7. 25 Feb 2022, Aeromedical evacuation record and admission notes, Military health facility
8. 18 Aug 2022, Respiratory consultation, lung function tests and HRCT report, Respiratory physician
9. 14 Mar 2023, Respiratory review, lung function and cardiopulmonary exercise test, Respiratory physician
10. 12 Jul 2024, Medical discharge documentation, Medical Officer
11. Statement of Principles concerning Coronavirus Disease 2019 (COVID-19) (Balance of Probabilities) No. 47 of 2020, Repatriation Medical Authority
12. Statement of Principles concerning Coronavirus Disease 2019 (COVID-19) (Reasonable Hypothesis) No. 46 of 2020, Repatriation Medical Authority