Influenza — DVA claim example

Diagnostic Assessment — Influenza

Example 1 of 2 · fictitious patient (Veteran P)

Diagnostic Assessment

Influenza

SOP Codes: Balance of Probabilities: No. 45 of 2017 Reasonable Hypothesis: No. 46 of 2017

ADF History

The veteran, Warehouse Operator, enlisted 15/08/2012, discharged 16/06/2015.

Occupational History

As a Warehouse Operator in the Australian Army, the veteran would have been exposed to communal living conditions typical of military environments, increasing risk of infectious disease transmission. Military personnel live in close quarters, share facilities, and work in environments where respiratory infections can spread rapidly through populations. The occupation involves regular contact with other personnel and shared equipment, creating opportunities for viral transmission.

History

The veteran a Warehouse Operator with the Australian Army, developed influenza in March 2013 during his military service. The condition occurred during routine military duties and required medical assessment and temporary duty restrictions.

Timeline

• 24 Feb 2012 - the veteran presented with significant flu-like illness with "extremely lethargic with a headache and runny nose" with onset two days prior. He reported being "unable to sleep at all last night as he felt like he was getting hot flushes and sweats" indicating systemic symptoms consistent with influenza. Physical examination showed he "looks genuinely unwell" with stable vital signs but clear evidence of viral illness. The condition was diagnosed as "Influenza"and managed with supportive care including bed rest, increased fluid intake, and symptomatic medications. He was placed on restricted duties for recovery and to prevent transmission to other personnel.

Symptoms

At the time of injury, the veteran experienced typical influenza symptoms including lethargy, headache, runny nose, hot flushes, sweats, and general malaise. He appeared genuinely unwell on examination with systemic viral illness symptoms. The condition resolved with conservative management and supportive care.

Imaging

No imaging was performed for this condition.

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

Influenza (J11.1) DVA SOP Code: No. 45 of 2017 (Balance of Probabilities) ICD-10 Code: J11.1

Influenza is an acute respiratory tract infection caused by influenza viruses (types A, B, or C). It is characterized by the sudden onset of fever, cough, headache, muscle aches, fatigue, and respiratory symptoms. The condition typically lasts 7-10 days and can range from mild to severe illness. Influenza is highly contagious and spreads through respiratory droplets when infected individuals cough, sneeze, or talk. The viral infection affects the respiratory system and can cause systemic symptoms including fever, chills, body aches, and profound fatigue.

This represents a single acute episode of influenza occurring during military service.

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

When did the veteran first experience symptoms attributable to this condition? 22 February 2012 (two days prior to presentation on 24 February 2012) [CHART REVIEW.docx]

When did the veteran first present to a health / medical provider for this condition? 24 February 2012 - presented to military medical officer [CHART REVIEW.docx]

When was the condition confirmed / formally diagnosed? 24 February 2012 - diagnosed as "Influenza" by military medical officer [CHART REVIEW.docx]

When did the veteran first present to you (or your practice) for this condition? 14 January 2021

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

The diagnosis was confirmed based on clinical presentation and symptom pattern consistent with influenza. Key symptoms included extreme lethargy, headache, runny nose, hot flushes, sweats, and general malaise with acute onset. Physical examination revealed a patient who appeared genuinely unwell with viral illness. No specific laboratory investigations were performed as diagnosis was made on clinical grounds. The temporal pattern and symptom constellation were typical of influenza infection [CHART REVIEW.docx].

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.

Being exposed to influenza virus as specified, within the three weeks before the clinical onset of influenza - MET

• The veteran was serving in military environment with communal living conditions, shared facilities, and close contact with other personnel, providing exposure to influenza virus within three weeks of onset.

Inability to obtain influenza vaccination between ten days and six months before the clinical onset of influenza - MET

• No documentation of influenza vaccination prior to onset of illness, constituting inability to obtain appropriate preventive measures.

Inability to obtain appropriate clinical management for influenza - MET

• While basic supportive care was provided, there is no evidence of antiviral therapy or comprehensive clinical management being offered during the acute phase of illness.

Sequelae

This condition is not a sequelae of another known condition.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

There was an inability to attain appropriate medical management for this condition. The Full Federal Court in Brew v Repatriation Commission (12 July 1996) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. While supportive care was provided, there is no evidence that antiviral therapy was offered or considered, which would constitute appropriate clinical management for influenza. This constitutes an inability to get appropriate medical management and the factor is MET. This causes a permanent worsening of the condition by potentially prolonging the duration and severity of symptoms.

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

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Influenza

Example 2 of 2 · fictitious patient

Diagnostic Assessment Influenza BOP Code: 45 of 2017 (Influenza) RH Code: 44 of 2017 (Influenza)

ADF History

The veteran, date of birth [withheld], Royal Australian Navy, Boatswain's Mate, 30 October 1980 to 16 August 1987

History

The veteran's first documented diagnosis of influenza was on 22 April 1982 on a patrol boat, when he was treated with medications including Stemetil and Panadol and was unfit for duty for 2 days.

He presented again with influenza on 21 March 1987 at a patrol boat.

He had a 1-day history of runny nose, headache, cough, mild myalgia, nausea, general malaise, and chills

Timeline

22 Apr 1982 — ABSR the veteran, as a young adult, was diagnosed with influenza on a patrol boat.

He was treated with medications including Stemetil 5mg tds and Panadol.

Unfit for duty for 2 days. "Influenza" 21 Mar 1987 — ABSR the veteran, as a young adult, presented with a 1-day history of runny nose, headache, cough, mild myalgia, nausea, general malaise, and chills.

Temperature was 37.5°C.

Pulse 80.

Chest was clear.

Throat was red.

He was treated with Actifed CC, soluble aspirin, and Strepsils.

Excused duty for 2 days. "Influenza"

Symptoms

Runny nose, headache, cough, myalgia, nausea, malaise, chills, and mild fever (37.5°C), consistent with influenza

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

Influenza (ICD-10: J11.1).

Influenza is an acute viral respiratory infection characterised by fever, myalgia, headache, cough, and malaise.

Dates: Symptom onset: on or before 22 April 1982 (first documented episode).

First presentation: 22 April 1982, a patrol boat [CHART REVIEW document]; further episode 21 March 1987 [CHART REVIEW document].

Diagnosis confirmed: 22 April 1982.

First presentation to practice: 12 March 2022.

Confirmed: Clinical diagnosis of influenza by the medical officer on a patrol boat on 22 April 1982 [CHART REVIEW document] and by the medical officer at a patrol boat on 21 March 1987 [CHART REVIEW document].

Causes: DRCA legislation.

Influenza acquired during ADF service in communal naval living environment.

100% service-related

4. What do you consider to be the cause(s) of the condition in this veteran?

Legislation: The clinical onset of this condition was before 27 January 2001 (see

Date of Clinical Onset

Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).

This is therefore a DRCA claim.

Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.

The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.

Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.

Plausible links to service outside the SOP factors are set out below.

The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Definition: Influenza was diagnosed clinically by the treating medical officers on 22 April 1982 and 21 March 1987; laboratory confirmation of the virus was not routine at the time.

The features recorded in 1987 (cough, headache, generalised aches, malaise and a temperature of 37.5°C) are characteristic features listed in the SOP definition, and the clinical diagnosis is accepted as influenza within that definition.

Causative Factors — Balance of Probabilities (Statement of Principles concerning Influenza, No.

45 of 2017) Factor 9(1): being exposed to influenza virus as specified, within the three weeks before the clinical onset of influenza — MET - Influenza spreads from infected people by respiratory droplets, direct contact and contaminated objects, with an incubation period of about one to four days, so the veteran's influenza diagnosed on 22 April 1982 necessarily followed exposure to the virus within the three weeks before.

He was then a member of the Boatswain's Mate of a patrol boat, a Boatswain's Mate ship, where he worked and messed, and at sea slept, in confined shared spaces within two metres of other crew members.

On the balance of probabilities he was infected through close exposure to an infected shipmate or contaminated shared objects, or by being in the same immediate work environment as a person with influenza.

Factor 9(2): for avian influenza only, being exposed to an avian influenza virus as specified, within the three weeks before the clinical onset of influenza — NOT MET - This factor applies only to avian influenza; the veteran's influenza was ordinary human influenza, and there is no record of exposure to birds, poultry or a person infected with avian influenza.

Factor 9(3): for swine influenza only, being exposed to a swine influenza virus as specified, within the three weeks before the clinical onset of influenza — NOT MET - This factor applies only to swine influenza; the veteran's influenza was ordinary human influenza, and there is no record of exposure to pigs, pork products or a person infected with swine influenza.

Factor 9(4): inability to obtain influenza vaccination between ten days and six months before the clinical onset of influenza — MET - The relevant window is 24 March to 12 April 1982.

His surviving service medical records contain no record that influenza vaccine was offered to him or given at any time.

As an adult junior sailor he depended on the Navy for his immunisations, and from January 1982 he was serving on a patrol boat, a survey ship based at a patrol boat, where at sea his health care was limited to the ship's medical staff, and he had no practical means of obtaining the vaccine outside the service.

On the available evidence, and on the beneficial approach, he was unable to obtain influenza vaccination in that window.

Factor 9(5): for severe influenza only: (a) having a medical condition as specified at the time of the clinical onset of influenza; or (b) being in the third trimester of pregnancy or the following six weeks before the clinical onset of influenza — NOT MET - This factor applies only to severe influenza; the veteran's influenza was not complicated by pneumonia or any other specified complication and did not require hospitalisation, and he had no specified medical condition in 1982.

Part (b) cannot apply to a man.

Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Influenza, No.

44 of 2017) the veteran had no operational deployments.

The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.

Factor 9(1): being exposed to influenza virus as specified, within the three weeks before the clinical onset of influenza — MET - Because influenza is acquired only through exposure to the virus from infected people or contaminated objects, with an incubation period of a few days, the veteran's influenza of 22 April 1982 followed such exposure within the preceding three weeks.

At that time he served on a patrol boat, where he worked and messed in close quarters with the Boatswain's Mate, and the exposure was most probably close exposure to an infected person or contaminated object, or being in the same immediate work environment as a person with influenza.

Factor 9(2): for avian influenza only, being exposed to an avian influenza virus as specified, within the three weeks before the clinical onset of influenza — NOT MET - This factor applies only to avian influenza, which the veteran did not have; there is no record of exposure to birds, poultry or a person with avian influenza.

Factor 9(3): for swine influenza only, being exposed to a swine influenza virus as specified, within the three weeks before the clinical onset of influenza — NOT MET - This factor applies only to swine influenza, which the veteran did not have; there is no record of exposure to pigs, pork products or a person with swine influenza.

Factor 9(4): inability to obtain influenza vaccination between ten days and six months before the clinical onset of influenza — MET - No influenza vaccination is recorded at any time in the veteran's service, including the window from 24 March to 12 April 1982.

As an adult sailor dependent on the Navy for his immunisations, serving from January 1982 on the survey ship a patrol boat, he had no practical means of obtaining the vaccine outside the service, so on the available evidence he was unable to obtain influenza vaccination in that period.

Factor 9(5): for severe influenza only: (a) having a medical condition as specified at the time of the clinical onset of influenza; or (b) being in the third trimester of pregnancy or the following six weeks before the clinical onset of influenza — NOT MET - This factor applies only to severe influenza, and the veteran's influenza of 22 April 1982 was neither complicated nor treated in hospital; he had none of the specified medical conditions, and pregnancy cannot apply to a man.

Other Plausible Links to Service Influenza spreads most readily where people live and work at close quarters.

The veteran's first documented episode arose in April 1982 while he was serving on a patrol boat, a survey ship whose company shared confined mess decks, sleeping quarters, bathrooms and working spaces, conditions that favour droplet and contact transmission.

The infection therefore arose in the course of his service and was contributed to by the communal conditions of shipboard life.

His second documented episode, on 21 March 1987, arose while he was serving at a patrol boat and was followed by a productive cough treated on 25 March 1987; it too arose during full-time service in a communal naval working environment.

Conclusion the veteran's influenza was caused by infection with influenza virus acquired through close exposure to infected shipmates or contaminated shared objects in the three weeks before its onset on 22 April 1982, while he was serving on a patrol boat, and there is no record that influenza vaccination was available to him beforehand.

The crowded, communal conditions of shipboard service provided the exposure, and his second documented episode in March 1987 also arose during full-time service, so the condition arose in the course of, and was contributed to by, his service.

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

Worsening Factors In the alternative, if the veteran's influenza is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 22 April 1982 aggravated it or contributed to it in a material degree.

His second documented episode, on 21 March 1987, was a fresh infection rather than a worsening of the first.

Worsening Factors — Balance of Probabilities (Statement of Principles concerning Influenza, No.

45 of 2017) Factor 9(6): inability to obtain appropriate clinical management for influenza — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no inability to obtain appropriate clinical management: his influenza was treated on a patrol boat on the day of presentation, 22 April 1982, with two days off duty and no recorded complication, and his March 1987 episode was treated and reviewed promptly at a patrol boat.

Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Influenza, No.

44 of 2017) the veteran had no operational deployments.

The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.

Factor 9(6): inability to obtain appropriate clinical management for influenza — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999) requires, the veteran's influenza was treated promptly on 22 April 1982 on a patrol boat, and his March 1987 episode was treated and reviewed at a patrol boat; there was no inability to obtain appropriate clinical management

Sequelae, Unintended Consequence, Inability

No specific sequelae.

Not an unintended consequence.

Not applicable

Date of Clinical Onset

Influenza is an acute condition.

Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.

Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.

Date of injury / illness: 22 April 1982 — first documented episode of influenza aboard a patrol boat [CHART REVIEW document].

The later records, including the further episode of 21 March 1987, concern investigation or follow-up and do not alter the date of clinical onset.

Date of clinical onset: 22 April 1982.

This date falls within the veteran's ADF service (30 October 1980 16 August 1987).

In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening