Latent Tuberculosis

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Latent Tuberculosis

Example 1 of 1 · fictitious patient (Veteran DQ)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

BOP Code: 48 of 2024 (Tuberculosis)
RH Code: 47 of 2024 (Tuberculosis)

ADF History

Veteran DQ, date of birth 23 August 1970, Australian Army, Combat Engineer (Sapper, later Plant and Construction Supervisor), enlisted 05 February 1990, medically discharged 18 September 2020. Operational service: Somalia, 15 January 1993 to 20 May 1993 (warlike); Rwanda, 10 February 1995 to 25 August 1995 (non-warlike); East Timor, 20 September 1999 to 15 April 2000 (warlike); Afghanistan, 01 February 2017 to 15 August 2017 (warlike); Iraq, 01 June 2018 to 10 November 2018 (warlike, ended by aeromedical evacuation).

Occupational History

As a combat engineer and later a plant and construction supervisor the veteran drilled, blasted, quarried and cut rock and concrete, built roads, bunkers and protective works, and operated crushing and earthmoving plant, often in tunnels, bunkers and enclosed structures and in dusty open worksites. Deployed construction tasks involved working and living alongside local national labourers and contractors in crowded, poorly ventilated accommodation and worksites.

The trade carries heavy exposure to respirable crystalline silica, diesel exhaust and combustion products, and the service culture of the period involved heavy drinking and smoking in messes, vehicles and accommodation thick with tobacco smoke. Deployed locations in Africa, Timor-Leste, Afghanistan and Iraq have a high incidence of tuberculosis, and screening, preventive treatment and specialist infectious diseases care were limited on operations.

History

Veteran DQ, a combat engineer in the Australian Army, acquired latent tuberculosis on warlike service in Afghanistan in 2017 after working for three weeks beside a local labourer with cavitary pulmonary tuberculosis, with interferon-gamma release assay conversion confirmed on 15 June 2017. The latent infection was not treated and progressed to active pulmonary tuberculosis on warlike service in Iraq on 02 November 2018, on a background of immunosuppression for lupus nephritis, cirrhosis, diabetes, silica exposure, heavy smoking and alcohol use disorder.

Timeline

20 May 1995 — During non-warlike service in Rwanda the veteran helped evacuate and treat large numbers of wounded civilians after a mass-casualty massacre, with heavy contact with blood and no gloves available. Hepatitis C infection was confirmed in 2002. His alcohol intake rose after this deployment to about 60 grams a day, and a psychiatrist diagnosed alcohol use disorder in 2010. He had smoked 20 cigarettes a day since 1988. "blood exposure, later hepatitis C"
14 Jun 2016 — A gastroenterologist confirmed compensated cirrhosis from alcohol and hepatitis C on elastography and biopsy. The veteran had undergone a partial gastrectomy in 2011 for a perforated gastric ulcer caused by anti-inflammatory medication for service injuries, had had type 2 diabetes since 2012, and had systemic lupus erythematosus diagnosed in 2014. A high-grade non-muscle-invasive bladder carcinoma diagnosed in 2015 had been treated with resection and intravesical BCG therapy from June 2015 to June 2016. "cirrhosis, alcohol and hepatitis C"
15 Oct 2016 — Investigation of perineal pain and a raised PSA showed granulomatous prostatitis, and culture of the prostate biopsy grew Mycobacterium bovis BCG. A urologist and infectious diseases physician diagnosed active BCG disease following intravesical BCG therapy and gave isoniazid, rifampicin and ethambutol to 15 January 2017. "BCG prostatitis, M. bovis BCG"
10 Jan 2017 — At his pre-deployment medical an interferon-gamma release assay was negative and the chest X-ray was normal. BCG vaccination was considered by the medical officer because of the high incidence of tuberculosis in his area of deployment and his liver disease, but no BCG vaccine was available to Defence health services because of a national supply shortage, and no alternative was arranged. "IGRA negative, BCG unavailable"
28 Mar 2017 — On warlike service in Afghanistan the veteran supervised a construction crew from 05 to 28 March 2017 that included a local labourer with a chronic cough who shared his site office, vehicle and meal breaks for about eight hours a day. The labourer was diagnosed with smear-positive cavitary pulmonary tuberculosis. In April 2017 the veteran also ate unpasteurised goat cheese and drank raw milk at key leader engagements; a veterinary team later confirmed bovine tuberculosis in the village herd. "close contact, smear-positive TB"
15 Jun 2017 — Contact tracing at the role 3 hospital showed a positive interferon-gamma release assay (QuantiFERON 2.8 IU/mL, nil 0.05), with a normal chest X-ray, no cough, fever or weight loss and negative sputum. A medical officer diagnosed latent tuberculosis infection. Preventive treatment was deferred to his return to Australia because of his cirrhosis. "QuantiFERON 2.8, latent TB"
22 Aug 2017 — An infectious diseases physician confirmed latent tuberculosis infection and recommended four months of rifampicin under joint hepatology monitoring. No hepatology service was available at his remote posting and treatment was not started. In March 2018 mycophenolate 1 g twice daily and prednisolone 15 mg daily were started for lupus nephritis, and from January 2018 he used fluticasone 500 micrograms twice daily for asthma that followed burn pit smoke exposure in Afghanistan. "LTBI confirmed, treatment not started"
02 Nov 2018 — On warlike service in Iraq the veteran presented with six weeks of productive cough, night sweats, 7 kg weight loss and haemoptysis. Chest X-ray showed right upper lobe consolidation with cavitation, and sputum was smear-positive with Mycobacterium tuberculosis on nucleic acid testing, sensitive to first-line drugs. Active pulmonary tuberculosis was diagnosed and he was evacuated on 10 November 2018. "cavitary pulmonary TB, smear-positive"

Symptoms

Latent tuberculosis infection causes no symptoms. At onset the veteran was well, with a normal chest X-ray and negative sputum, and the infection was detected by a positive interferon-gamma release assay on contact tracing. When it progressed to active pulmonary tuberculosis in 2018 he had productive cough, night sweats, fevers, weight loss and haemoptysis.

He now reports breathlessness on exertion, a chronic cough and reduced exercise tolerance after completing treatment, with residual right upper lobe scarring and bronchiectasis.

Imaging

10 Jan 2017 — Chest X-ray: "Clear lungs. No hilar lymphadenopathy, consolidation or calcified granuloma."
15 Jun 2017 — Chest X-ray: "Clear lungs. No features of active or previous pulmonary tuberculosis."
02 Nov 2018 — Chest X-ray and CT chest: "Right upper lobe consolidation with a 3.2 cm thick-walled cavity and tree-in-bud nodularity in the right upper and middle lobes, consistent with active pulmonary tuberculosis. Background mild centrilobular emphysema."

Onset Date

The most likely date of onset of this condition is 15 Jun 2017.

At that date the veteran was on warlike service in Afghanistan as a plant and construction supervisor. Eleven weeks after three weeks of daily close contact with a labourer who had smear-positive cavitary pulmonary tuberculosis, contact tracing showed a positive interferon-gamma release assay with a normal chest X-ray and no symptoms, establishing latent tuberculosis infection.

This date is appropriate because his interferon-gamma release assay on 10 January 2017 was negative, and the first positive assay was on 15 June 2017. Latent infection has no symptoms, and the date of the first positive test after a documented exposure is the date on which the condition is established. The assay is unaffected by his earlier BCG exposure.

For the exposure and food factors, the period at least 14 days before onset runs to 01 Jun 2017; the contact from 05 to 28 March 2017 and the unpasteurised dairy products in April 2017 fall within it. For the high-incidence area factor, he lived and worked in Afghanistan from 01 Feb 2017 to onset, and his only test between arrival and onset was the positive assay. The intravesical BCG therapy of June 2015 to June 2016 and the failed attempt to obtain BCG vaccination in January 2017 both preceded onset.

For the worsening factors, the documented worsening was the progression to active pulmonary tuberculosis on 02 Nov 2018. The 12 months before it run from 02 Nov 2017 to 02 Nov 2018, during which he smoked 20 cigarettes a day and drank about 60 grams of alcohol a day. The 6 months before it run from 02 May 2018 to 02 Nov 2018, and the 3 months from 02 Aug 2018 to 02 Nov 2018, during which he used fluticasone 1,000 micrograms daily. Mycophenolate, prednisolone, cirrhosis, diabetes, hepatitis C and alcohol use disorder were present at the worsening, and the gastrectomy, lupus, silica and tobacco smoke exposures preceded it.

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

The formal diagnosis is Latent Tuberculosis Infection (ICD-10-AM Z22.7), which progressed to active pulmonary tuberculosis (A15.0) in November 2018, under the Statements of Principles concerning tuberculosis, Balance of Probabilities No. 48 of 2024 and Reasonable Hypothesis No. 47 of 2024.

Tuberculosis is infection with bacteria of the Mycobacterium tuberculosis complex, which includes M. tuberculosis and M. bovis, including the BCG strain. It is usually acquired by inhaling droplets from a person with infectious pulmonary disease, and less often by consuming unpasteurised dairy products from infected animals. Most infected people contain the infection without symptoms, a state called latent tuberculosis, detected by a tuberculin skin test or interferon-gamma release assay with a normal chest X-ray. About 5 to 10 per cent progress to active disease over their lifetime, a risk greatly increased by immunosuppression, diabetes, cirrhosis, silica exposure, smoking, alcohol and gastrectomy. Preventive treatment of latent infection substantially reduces that risk.

The infection was acquired on warlike service in Afghanistan, with onset confirmed on 15 June 2017, and it worsened by progressing to active pulmonary tuberculosis on warlike service in Iraq on 02 November 2018.

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

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

15 June 2017.

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

15 June 2017.

When was the condition confirmed / formally diagnosed?

15 June 2017.

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

29 October 2025.

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

Latent tuberculosis infection was diagnosed on 15 June 2017 on a positive interferon-gamma release assay (QuantiFERON 2.8 IU/mL) after documented close contact with infectious pulmonary tuberculosis, with a normal chest X-ray, no symptoms and negative sputum excluding active disease. The negative assay on 10 January 2017 documents conversion during deployment. This meets the Statement of Principles definition of tuberculosis, which includes latent tuberculosis.

An infectious diseases physician confirmed the diagnosis on 22 August 2017. The worsening was confirmed on 02 November 2018 by right upper lobe cavitation on imaging and smear-positive sputum with Mycobacterium tuberculosis on nucleic acid testing and culture. The earlier BCG prostatitis of 2016 was confirmed on culture of the prostate biopsy.

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 15 June 2017, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to his warlike and non-warlike service in Somalia, Rwanda, East Timor, Afghanistan, where the infection was acquired, and Iraq, where it progressed to active disease. Factors 9(6) onwards in each instrument are worsening factors that apply to aggravation of the condition.

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 Tuberculosis, No. 48 of 2024

Causative factors

Factor 9(1): being exposed to bacteria belonging to the Mycobacterium tuberculosis complex at least 14 days before the clinical onset of tuberculosis; — MET

- From 05 to 28 March 2017 the veteran shared a site office, vehicle and meal breaks for about eight hours a day with a labourer in his construction crew who was diagnosed with smear-positive cavitary pulmonary tuberculosis. The exposure ended 11 weeks before onset on 15 June 2017. It arose from his duties as construction supervisor.

Factor 9(2): living or working in an area which has an incidence of tuberculosis of at least 50 cases per 100,000 of population per year, before the clinical onset of tuberculosis, provided that the individual had no negative test results for tuberculosis in any intervening period between living or working in the affected area and the onset of tuberculosis; — MET

- The veteran lived and worked in Afghanistan, where the incidence of tuberculosis was about 190 cases per 100,000 per year, from 01 February 2017 to onset on 15 June 2017. He had no negative test between arriving and onset; his last negative assay, on 10 January 2017, was before he arrived.

Factor 9(3): consuming unpasteurised milk, unpasteurised dairy products or uncooked meat from an animal infected with Mycobacterium bovis or Mycobacterium caprae at least 14 days before the clinical onset of tuberculosis; — MET

- In April 2017, at key leader engagements that were part of his duties, the veteran drank raw goat milk and ate unpasteurised goat cheese from a village herd in which a veterinary team later confirmed bovine tuberculosis. This was more than 14 days before onset.

Factor 9(4): for active tuberculosis disease due to infection with Mycobacterium bovis BCG only: (a) having intravesical BCG therapy for malignant neoplasm of the bladder; or (b) being vaccinated with BCG vaccine; before the clinical onset of tuberculosis; — MET

- The veteran received intravesical BCG therapy for a high-grade bladder carcinoma from June 2015 to June 2016, prescribed by a Defence-funded urologist while he was serving. He developed active tuberculosis disease due to Mycobacterium bovis BCG, with granulomatous prostatitis confirmed on culture on 15 October 2016. The BCG therapy preceded that onset.

Factor 9(5): inability to access appropriate tuberculosis vaccination in accordance with contemporary medical standards before the clinical onset of tuberculosis; — MET

- At his pre-deployment medical on 10 January 2017 the medical officer considered BCG vaccination appropriate because of his deployment to a high-incidence area and his liver disease, but no BCG vaccine was available to Defence health services because of a national supply shortage and no alternative was arranged before onset.

Worsening factors

Factor 9(6): having a substantially compromised immune system due to: (a) chronic renal failure; (b) haematological malignancy; (c) infection with human immunodeficiency virus; (d) severe malnutrition; (e) solid organ, stem cell or bone marrow transplantation; or (f) taking an immunosuppressive drug; at the time of the clinical worsening of tuberculosis; — MET

- From March 2018 the veteran took mycophenolate 1 g twice daily and prednisolone 15 mg daily, prescribed by a Defence-funded nephrologist for lupus nephritis. He was taking these immunosuppressive drugs at the worsening on 02 November 2018.

Factor 9(7): inhaling at least 1,000 micrograms of beclomethasone, or equivalent inhaled glucocorticoid daily for the 6 months, before the clinical worsening of tuberculosis, and where the treatment has ceased, the last inhaled glucocorticoid dose was taken within the 30 days before the clinical worsening of tuberculosis; — MET

- The veteran inhaled fluticasone 500 micrograms twice daily, equivalent to about 2,000 micrograms of beclomethasone, from January 2018 to the worsening, covering the 6 months from 02 May 2018 to 02 November 2018. It was prescribed for asthma that followed burn pit smoke exposure on deployment.

Factor 9(8): having cirrhosis of the liver at the time of the clinical worsening of tuberculosis; — MET

- Cirrhosis from alcohol and hepatitis C was confirmed on elastography and biopsy on 14 June 2016 and was present at the worsening on 02 November 2018.

Factor 9(9): having diabetes mellitus at the time of the clinical worsening of tuberculosis; — MET

- Type 2 diabetes mellitus, diagnosed in 2012 and worsened by prednisolone, was present at the worsening, with an HbA1c of 8.9 per cent in October 2018.

Factor 9(10): inhaling respirable crystalline silica dust in an enclosed space: (a) for a cumulative period of at least 3,000 hours before the clinical worsening of tuberculosis; and (b) at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting; before the clinical worsening of tuberculosis; — MET

- The veteran's service record and supervisor statements document about 3,400 hours of drilling and cutting rock and concrete inside tunnels, bunkers and enclosed structures between 1990 and 2016, without respiratory protection for most of that time, before the worsening.

Factor 9(11): inhaling respirable crystalline silica dust in an open environment: (a) for a cumulative period of at least 6,000 hours before the clinical worsening of tuberculosis; and (b) at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting; before the clinical worsening of tuberculosis; — MET

- The veteran worked about 6,800 hours at open quarries, crushing plant and road and base construction sites while rock was being drilled, blasted, crushed and cut, between 1990 and 2018, before the worsening.

Factor 9(12): for pulmonary tuberculosis only, smoking at least 1 cigarette per day, or the equivalent thereof in other tobacco products, for at least the 12 months before the clinical worsening of tuberculosis; — MET

- The worsening was to active pulmonary tuberculosis. The veteran smoked 20 cigarettes a day throughout the 12 months before the worsening, from 02 November 2017 to 02 November 2018, a habit he began at 18 and maintained throughout his service.

Factor 9(13): consuming at least 40 grams of alcohol per day for at least the 12 months before the clinical worsening of tuberculosis; — MET

- The veteran drank about 60 grams of alcohol a day throughout the 12 months before the worsening, an intake that rose after his deployment to Rwanda in 1995.

Factor 9(14): having alcohol use disorder at the time of the clinical worsening of tuberculosis; — MET

- A psychiatrist diagnosed alcohol use disorder in 2010, and it was present at the worsening.

Factor 9(15): having hepatitis C infection at the time of the clinical worsening of tuberculosis; — MET

- Chronic hepatitis C, confirmed in 2002 and acquired from blood exposure while treating casualties in Rwanda, was present at the worsening, with detectable HCV RNA in 2018.

Factor 9(16): inability to obtain appropriate clinical management for tuberculosis before the clinical worsening of tuberculosis; — MET

- Preventive treatment for latent tuberculosis was recommended on 22 August 2017 but was never started, because no hepatology monitoring was available at his remote posting, and he was then immunosuppressed and deployed without it. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the worsening.

Reasonable Hypothesis — Statement of Principles concerning Tuberculosis, No. 47 of 2024

Causative factors

Factor 9(1): being exposed to bacteria belonging to the Mycobacterium tuberculosis complex at least 14 days before the clinical onset of tuberculosis; — MET

- The three weeks of daily close contact with a labourer with smear-positive cavitary pulmonary tuberculosis, from 05 to 28 March 2017, occurred on warlike service in Afghanistan, more than 14 days before onset on 15 June 2017.

- The veteran lived and worked in Afghanistan on warlike service from 01 February 2017 to onset, and earlier in Somalia, Rwanda and East Timor, all with an incidence above 50 per 100,000. He had no negative test between his arrival in Afghanistan and onset.

- The raw goat milk and unpasteurised cheese from a herd with confirmed bovine tuberculosis were consumed at key leader engagements on warlike service in Afghanistan in April 2017, more than 14 days before onset.

- Intravesical BCG therapy from June 2015 to June 2016 preceded active BCG disease, confirmed on 15 October 2016. The bladder carcinoma it treated was recorded by the urologist as related to his diesel exhaust and combustion product exposure on operations and his service smoking.

Factor 9(5): inability to access appropriate tuberculosis vaccination in accordance with contemporary medical standards before the clinical onset of tuberculosis; — MET

- BCG vaccination considered appropriate before his warlike deployment to Afghanistan could not be obtained through Defence health services in January 2017 because of a supply shortage, and he deployed unvaccinated.

Worsening factors

- Mycophenolate and prednisolone for lupus nephritis were being taken at the worsening on warlike service in Iraq on 02 November 2018.

Factor 9(7): inhaling at least 1,000 micrograms of beclomethasone, or equivalent inhaled glucocorticoid daily for the 3 months, before the clinical worsening of tuberculosis, and where the treatment has ceased, the last inhaled glucocorticoid dose was taken within the 30 days before the clinical worsening of tuberculosis; — MET

- Fluticasone equivalent to about 2,000 micrograms of beclomethasone daily, for asthma following burn pit smoke exposure on warlike service in Afghanistan, was inhaled throughout the 3 months before the worsening, from 02 August 2018 to 02 November 2018, on warlike service in Iraq.

Factor 9(8): having cirrhosis of the liver at the time of the clinical worsening of tuberculosis; — MET

- Cirrhosis from hepatitis C acquired on service in Rwanda and alcohol use that escalated after that deployment was present at the worsening in Iraq.

Factor 9(9): having diabetes mellitus at the time of the clinical worsening of tuberculosis; — MET

- Type 2 diabetes mellitus, poorly controlled on warlike service in Iraq with an HbA1c of 8.9 per cent, was present at the worsening.

Factor 9(10): inhaling respirable crystalline silica dust in an enclosed space: (a) for a cumulative period of at least 1,500 hours before the clinical worsening of tuberculosis; and (b) at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting; before the clinical worsening of tuberculosis; — MET

- The veteran drilled and cut rock and concrete in bunkers and enclosed structures for about 1,650 hours on warlike service in East Timor in 1999 and 2000 and in Afghanistan in 2017, within his total of about 3,400 enclosed hours, before the worsening.

Factor 9(11): inhaling respirable crystalline silica dust in an open environment: (a) for a cumulative period of at least 3,000 hours before the clinical worsening of tuberculosis; and (b) at the time material containing crystalline silica was being produced, excavated, drilled, cut or ground, or used in construction, manufacturing, cleaning or blasting; before the clinical worsening of tuberculosis; — MET

- He worked about 3,200 hours at open quarries and road and base construction sites on operational service in Somalia, Rwanda, East Timor, Afghanistan and Iraq while rock was drilled, crushed and cut, before the worsening.

- The veteran smoked 20 cigarettes a day throughout the 12 months before the progression to pulmonary tuberculosis, including on warlike service in Iraq from June 2018.

Factor 9(13): for pulmonary tuberculosis only, being in an atmosphere with a visible tobacco smoke haze in an enclosed space for at least 5,000 hours before the clinical worsening of tuberculosis; — MET

- The veteran spent more than 5,000 hours in messes, accommodation, vehicles and site offices with a visible tobacco smoke haze between 1990 and 2005, including crowded shelters on warlike service in Somalia and East Timor, before the worsening to pulmonary tuberculosis.

Factor 9(14): having a gastrectomy or jejunoileal bypass before the clinical worsening of tuberculosis; — MET

- A partial gastrectomy was performed in 2011 for a perforated gastric ulcer caused by anti-inflammatory medication for injuries that included a knee injury on warlike service in East Timor, before the worsening.

Factor 9(15): consuming at least 40 grams of alcohol per day for at least the 12 months before the clinical worsening of tuberculosis; — MET

- The veteran drank about 60 grams of alcohol a day throughout the 12 months before the worsening, an intake that began after his service in Rwanda and continued on warlike service in Iraq.

Factor 9(16): having alcohol use disorder at the time of the clinical worsening of tuberculosis; — MET

- Alcohol use disorder, related by the treating psychiatrist to traumatic experiences on service in Rwanda and Somalia, was present at the worsening.

Factor 9(17): having systemic lupus erythematosus before the clinical worsening of tuberculosis; — MET

- Systemic lupus erythematosus was diagnosed in 2014, with lupus nephritis in 2018, and was present before the worsening on warlike service in Iraq. The rheumatologist recorded his silica exposure on operations as a recognised contributor.

Factor 9(18): having hepatitis C infection at the time of the clinical worsening of tuberculosis; — MET

- Chronic hepatitis C from blood exposure while treating casualties on non-warlike service in Rwanda in 1995 was present at the worsening.

Factor 9(19): inability to obtain appropriate clinical management for tuberculosis before the clinical worsening of tuberculosis; — MET

- Preventive treatment was deferred on warlike service in Afghanistan in June 2017, was not started afterwards because hepatology monitoring was unavailable at his posting, and was not available on warlike service in Iraq, where the infection progressed to active disease.

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

Sequelae

The latent tuberculosis is a sequela of the veteran's close contact with infectious tuberculosis and his consumption of unpasteurised dairy products on warlike service in Afghanistan, and its progression was driven by the immunosuppressive treatment of his lupus nephritis and by his service-related cirrhosis, hepatitis C, alcohol use disorder and diabetes. In turn the active disease has caused right upper lobe scarring and bronchiectasis, with chronic cough and breathlessness, and the rifampicin-based treatment destabilised his diabetes and liver function.

Unintended Consequence

Met. The active BCG disease of 2016 was an unintended consequence of intravesical BCG therapy provided and paid for by the Commonwealth while the veteran was serving, and the progression of the latent infection to active tuberculosis was promoted by mycophenolate, prednisolone and high-dose inhaled fluticasone prescribed by Defence-funded clinicians before preventive treatment had been given (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. BCG vaccination considered appropriate before his deployment could not be obtained in January 2017. After the latent infection was diagnosed on warlike service in Afghanistan on 15 June 2017, preventive treatment was deferred, and after his return it was recommended on 22 August 2017 but never started, because no hepatology monitoring was available at his remote posting. He was then immunosuppressed and deployed to Iraq without preventive treatment, and the infection progressed to cavitary pulmonary tuberculosis on 02 November 2018. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of vaccination, monitoring and preventive treatment because of his service circumstances amounts to an inability to obtain appropriate clinical management before the clinical worsening.

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

See attached report.

References

20 May 1995, Deployed health record, Medical Officer, Rwanda
14 Jun 2016, Gastroenterology consultation, elastography and liver biopsy report, Gastroenterologist
15 Oct 2016, Prostate biopsy microbiology report and specialist letters, Urologist and Infectious diseases physician
10 Jan 2017, Pre-deployment medical examination, interferon-gamma release assay and chest X-ray reports, Medical Officer
28 Mar 2017, Contact tracing record and veterinary report, Preventive medicine officer and Veterinary officer, Afghanistan
15 Jun 2017, Deployed health record, interferon-gamma release assay and chest X-ray reports, Medical Officer, Role 3 hospital, Afghanistan
22 Aug 2017, Specialist consultation, Infectious diseases physician
12 Mar 2018, Nephrology consultation and renal biopsy report, Nephrologist
02 Nov 2018, Deployed health record, chest imaging and sputum microbiology reports, Medical Officer, Role 3 hospital, Iraq
Statement of Principles concerning Tuberculosis (Balance of Probabilities) No. 48 of 2024, Repatriation Medical Authority
Statement of Principles concerning Tuberculosis (Reasonable Hypothesis) No. 47 of 2024, Repatriation Medical Authority

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