Statement of Principles concerning hookworm infection (Balance of Probabilities) (No. 68 of 2025)

This instrument is a Statement of Principles (SoP) determined by the Repatriation Medical Authority under subsection 196B(3) of the Veterans' Entitlements Act 1986, concerning hookworm infection and death from hookworm infection (Balance of Probabilities) (No. 68 of 2025) (section 3; title). Mechanically, it replaces the earlier Statement of Principles concerning hookworm disease (No. 8 of 2017) by express repeal (section 4), and it commences operation on 22 September 2025 (section 2).

Substantively, the SoP does the following things, in the terms of the instrument:

• Defines the injury/disease that the SoP covers (hookworm infection and death from hookworm infection) and specifies the scope of that meaning beyond mere ICD‑10‑AM coding (section 7(1)-(4)). It lists the species covered: Necator americanus, Ancylostoma duodenale, Ancylostoma ceylanicum, Ancylostoma caninum, Ancylostoma braziliense, Ancylostoma tubaeforme, Uncinaria stenocephela, and Bunostomum phlebotomum (section 7(2)(1)). It expressly includes intestinal and extraintestinal forms (cutaneous larva migrans) (section 7(2)(2) and notes).
• Declares that death caused by, or to which hookworm infection contributed, is included (section 7(3)), and provides a Schedule definition of “terminal event” with enumerated examples (Schedule 1).
• Sets the causation/connectivity criteria that a claimant must meet on the balance of probabilities for a link between the condition and relevant service: at least one of a set of exposure factors within six years before clinical onset, or inability to obtain appropriate clinical management before clinical worsening (section 9). The listed exposures include contact with soil or sand contaminated with larvae; contact with human or animal faeces contaminated with larvae; ingestion of contaminated food, drink or dust; being in tropical or subtropical regions with poor sanitation; and being in warm and damp conditions with poor sanitation (section 9(1)(a)-(e), with the six‑year temporal qualifier).
• Requires that any factor relied on must be related to the person's relevant service (section 10(1)), and it limits the application of the inability‑to‑obtain‑management factor to cases where the infection was suffered or contracted before or during, but did not arise out of, the person’s relevant service (section 10(2)).
• States that where a factor refers to an injury or disease covered by a different SoP determined under subsection 196B(3) of the VEA, the factors in that other SoP apply in accordance with its terms (section 11).

The instrument also clarifies the meaning of “relevant service” for its purposes (Schedule 1), listing eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA. It expressly notes that while hookworm infection attracts ICD‑10‑AM code B76, the operative meaning for application of the SoP is the species‑based definition in subsection 7(2) (section 7(4) and accompanying note).

The instrument gives the Repatriation Medical Authority’s view that, on the sound medical‑scientific evidence available, it is more probable than not that hookworm infection and death from hookworm infection can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA (section 8). That statement is framed as the Authority’s basis for the determinations in the SoP.

Mechanically therefore, the SoP supplies the medical criteria that will be applied in relation to claims that fall under section 120B of the VEA or section 339 of the MRCA (section 5). It does not, within its text, set benefit entitlements, monetary rates or administrative procedures; it sets what must be established, medically and factually, for a link to relevant service to be found under the claims provisions referred to (section 5).

The instrument is compact and focused on medical/causation criteria. The principal concepts it establishes are the definitional scope of the disease, the discrete exposure and treatment factors that can, singly, satisfy the causation threshold, the temporal window for exposure relative to clinical onset, and the relationship requirement to relevant service. These main concepts are stated in the text as follows.

Disease definition: “Hookworm infection” is defined by specific parasite species and includes both intestinal and extraintestinal forms (section 7(2)). The SoP explicitly displaces reliance on the ICD‑10‑AM code for definitional purposes by providing its own species‑based definition and directing that the meaning in subsection 7(2) governs application (section 7(4) and Note). The Schedule reiterates the cross‑reference (Schedule 1, definition of “hookworm infection”).

Included outcomes: “Hookworm infection” includes death from a terminal event or condition that was contributed to by the person’s hookworm infection (section 7(3)). The Schedule defines “terminal event” and lists representative causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (Schedule 1).

Causation factors: The SoP sets two alternative types of factors, either of which will suffice (section 9): (a) a range of exposure mechanisms that must have occurred within six years before clinical onset (section 9(1)); or (b) inability to obtain appropriate clinical management for hookworm infection before clinical worsening (section 9(2)). The exposure mechanisms are precisely enumerated (soil/sand contact contaminated with larvae; contact with contaminated human or animal faeces; ingestion of contaminated food, drink or dust; being in tropical/subtropical regions with poor sanitation; being in warm and damp conditions with poor sanitation) (section 9(1)(a)-(e)). The temporal qualifier “within the 6 years before clinical onset” attaches to those listed exposures (section 9(1) end).

Relationship to service: Any factor relied on must be related to the person’s relevant service (section 10(1)). The SoP further limits the operation of the clinical‑management factor: it applies only to material contribution to, or aggravation of, hookworm infection where the person’s hookworm infection was suffered or contracted before or during (but did not arise out of) the person’s relevant service (section 10(2)). That is a narrowly phrased restriction and therefore affects how evidence of healthcare access during service, or lack thereof, will be treated.

Inter‑SoP interaction: Where a factor in this SoP refers to an injury or disease covered by another SoP determined under subsection 196B(3) of the VEA, that other SoP’s factors apply according to its terms (section 11). This is a cross‑reference mechanism that delegates the factual/medical detail for overlapping conditions to the other SoP.

The instrument applies to persons bringing claims that fall within specific statutory pathways: claims to which section 120B of the Veterans' Entitlements Act 1986 (VEA) or section 339 of the Military Rehabilitation and Compensation Act 2004 (MRCA) applies (section 5). The Schedule defines “relevant service” for the instrument as eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1). Therefore, the primary affected groups, as framed by the document, are:

• Veterans or former members of the Forces with eligible war service or defence service categories under the VEA, as defined in the Schedule (Schedule 1); and
• Members (or former members) whose claims fall under peacetime service provisions of the MRCA (Schedule 1).

The instrument is addressed to claim processes under the two statutory provisions identified (section 5). It is not expressed to create entitlements directly; instead, it sets the medical/causation criteria that are to be applied within those claim processes. The Repatriation Medical Authority is the body that determined the SoP under subsection 196B(3) of the VEA (section 3), and the SoP therefore informs agencies and decision makers who apply the VEA and MRCA claim provisions as to the medical nexus required.

Who should care operationally:

• Claimants who assert that their hookworm infection or death from hookworm infection is connected to their relevant service must meet the factors in this SoP; the SoP supplies the medical tests that will be applied (sections 7-11).
• Medical practitioners preparing medico‑legal reports for such claims must address the specified exposures, the six‑year time window, and the inability‑to‑obtain‑management factor where relevant (section 9).
• Decision makers administering claims under s120B VEA or s339 MRCA will use this SoP as the medical benchmark for determining service connection for hookworm infection claims (section 5).
• Where a factor refers to a condition covered by another SoP, proponents and decision makers must consult that other SoP and apply its factors in accordance with its terms (section 11).

The SoP’s species list and inclusion of extraintestinal forms (cutaneous larva migrans) broaden the clinical types that can be claimed beyond a narrow ICD‑10 code reference; the instrument also notes that although ICD‑10‑AM code B76 is associated with hookworm, the operative meaning is the species‑based definition in subsection 7(2) (section 7(4) and note). Death claims are included, but the Schedule’s definition of “terminal event” circumscribes the kinds of proximate or ultimate causes that count as a death outcome contributed to by hookworm infection (section 7(3); Schedule 1).

The SoP itself does not create administrative duties in the sense of requiring specific conduct by particular agencies nor does it prescribe statutory rights or benefit entitlements. Instead, it prescribes the medical/causation criteria that must be established for a hookworm infection or death from hookworm infection to be taken, on the balance of probabilities, to be connected with relevant service in the context of claims under specified statutory provisions. That said, the instrument imposes several operational requirements and clarifies rights in a claims context as follows.

Duties of parties preparing or determining claims:

• Claimants must demonstrate the existence of at least one of the factors in section 9, and that the factor is related to their relevant service (sections 9 and 10(1)). The factors are either particular exposure mechanisms occurring within six years before clinical onset (section 9(1)) or inability to obtain appropriate clinical management before clinical worsening (section 9(2)).
• Where a claimant relies on a factor that refers to another injury or disease covered by a different SoP, those factors are to be applied according to that other SoP as in force from time to time (section 11). This means duty bearers must identify cross‑referenced SoPs and apply their terms appropriately.

Rights or entitlements insofar as the SoP operates in claims processes:

• The SoP establishes the medical bases that, if satisfied on the balance of probabilities in the claim process referred to (s120B VEA; s339 MRCA), connect hookworm infection or death from hookworm infection to relevant service (sections 5 and 8). The SoP is the metric by which the medical link is judged; it does not itself award service pensions or compensation but it governs the medical nexus required for such awards under the statute.
• For death claims, the SoP recognises the right to include death from a terminal event contributed to by the hookworm infection as within the disease concept covered by the SoP (section 7(3)). The Schedule’s definition of “terminal event” lists examples that will be considered as terminal events for the purposes of applying the SoP (Schedule 1).

Constraints and limits embedded in the SoP:

• The exposure factors in section 9(1) carry a specific temporal limit: exposures must have occurred within six years before clinical onset (section 9(1) end). That is an operative time‑limit that restricts the evidence that can satisfy the exposure alternative.

The Statement of Principles does not create criminal offences, civil penalties, or administrative sanctions, nor does it set enforcement mechanisms within its text. The instrument is a determinative medical standard for application within the claim processes identified; it is not drafted to prescribe penalties for non‑compliance or to create enforcement liabilities (no sections in the instrument reference penalties, sanctions, or enforcement powers). The only “authority” clause is that the instrument is made under subsection 196B(3) of the VEA (section 3), which is the statutory power under which the Repatriation Medical Authority determines SoPs.

Practical consequences (as derived from the SoP’s function rather than explicit sanctions):

• If a claimant cannot demonstrate at least one of the factors in section 9 and a requisite link to relevant service (section 10(1)), a claim under the statutory provisions referenced (s120B VEA, s339 MRCA) is unlikely to satisfy the medical nexus test that this SoP supplies. The SoP thus has consequences for claim outcomes, but those are administrative rather than punitive and are exercised through the claim decision process under the VEA and MRCA, not through any enforcement mechanism contained in the SoP itself (section 5).
• The SoP limits the evidentiary pathways available to claimants by specifying the exposures and temporal window, and by qualifying the inability‑to‑obtain‑management factor. Those limitations, while not framed as penalties, reduce the available grounds for establishing service connection, and therefore can affect the outcome of an administrative decision under the VEA or MRCA. Any adverse consequence arises through the statutory benefit/compensation decision machinery, not through penalties imposed by the SoP.

Absence of investigatory or compliance powers: The instrument does not confer investigatory powers on the Repatriation Medical Authority, nor does it stipulate compliance monitoring regimes. The SoP’s implementation and any compliance consequences are to occur within the administrative processes governed by the VEA and MRCA, which are not part of the instrument’s text (section 5). Where a factor refers to another SoP, the other SoP’s terms are to apply (section 11), but again no enforcement mechanisms are specified.

In sum, the SoP is a medical standard used to assess causal connection in claims; it does not itself establish penalties or enforcement pathways within its text.

The Statement of Principles is expressly made under subsection 196B(3) of the Veterans' Entitlements Act 1986 (section 3). Its stated scope is to apply to claims to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 (MRCA) applies (section 5). Hence, the SoP is an instrument that operates within the statutory framework of those Acts by defining the medical nexus to relevant service for hookworm infection and death from hookworm infection.

Interaction points and mechanics:

• Source power and statutory context: The SoP is a product of the Repatriation Medical Authority’s powers under the VEA (section 3). The Authority’s determinations under subsection 196B(3) are intended to inform the statutory decision makers who apply VEA and MRCA provisions when determining service connection for injuries and diseases. The SoP therefore functions as a medico‑scientific input into statutory decision‑making processes, rather than as stand‑alone primary legislation setting entitlements.
• Application to specified claims: The instrument explicitly applies to claims under section 120B VEA or section 339 MRCA (section 5). Those statutory provisions (not reproduced in the instrument) are the claim pathways within which the SoP’s medical criteria are to be assessed. Administrative decision makers applying those provisions will, consistent with statutory rules, use this SoP as the medical standard.
• Cross‑SoP references: The SoP contains an internal mechanism for cross‑SoP application: section 11 provides that if a factor in this SoP refers to an injury or disease covered by another SoP determined under subsection 196B(3) of the VEA, the factors in that other SoP apply according to that other SoP’s terms. This is an explicit delegating clause that binds users of this SoP to consult and apply other SoPs where relevant, creating a network of interrelated SoPs for overlapping or related conditions.
• Relationship to diagnostic coding standards: The SoP mentions ICD‑10‑AM coding , it notes that hookworm infection attracts ICD‑10‑AM code B76, but it clarifies that for the purposes of applying the SoP the operative meaning is the species‑based definition in subsection 7(2) (section 7(4) and note). For claims work, that means a diagnostic code alone is insufficient for the SoP’s application; the species and form must fit the SoP’s definition.
• Definitions that limit interaction: The Schedule’s definition of “relevant service” confines the SoP’s applicability to certain types of VEA/MRCA service categories (Schedule 1). That will limit the SoP’s reach in relation to other parts of the VEA or MRCA that deal with different service categories or different entitlement rules.

The instrument contains a single clear amendment action: it repeals the earlier Statement of Principles concerning hookworm disease (Balance of Probabilities) (No. 8 of 2017) (Federal Register of Legislation No. F2017L00012) made under subsection 196B(3) of the VEA (section 4). The new instrument is dated 22 August 2025 (front matter) and commences on 22 September 2025 (section 2), indicating a one‑month period between determination and commencement.

What is recorded within the text:

• Repeal: Section 4 expressly repeals the 2017 SoP (No. 8 of 2017). No other amendments to other instruments or cross‑references are present in the SoP text.
• Effective date versus determination date: The front matter records the SoP as dated 22 August 2025 (signature of the Chairperson); section 2 states commencement is 22 September 2025. That sequence is common for SoPs , the instrument is determined and then set to commence at a future date , and practitioners should note the dates for evidentiary and procedural purposes (front matter; section 2).
• No transitional provisions: The instrument does not include transitional provisions or savings clauses dealing with claims that were lodged or determined under the earlier 2017 SoP prior to the repeal. The text only effects a repeal. Therefore, any transitional handling of in‑flight claims would be governed by administrative practice or by the statutory provisions the SoP informs (sections 4 and 5). The instrument itself does not specify transitional rules.

Absence of further amendment data:

• The instrument does not provide a history of prior amendments beyond the express repeal of the 2017 SoP. No other amendment entries, schedules of changes, or legislative history is contained in the text.
• The SoP does not reference any amendments to the VEA or MRCA that may have prompted the new SoP; it states only that it is made under subsection 196B(3) of the VEA (section 3).

Implication for users:

• From the commencement date (22 September 2025) onward, this SoP replaces the 2017 instrument as the authoritative Statement of Principles concerning hookworm infection for the purposes of claims under the identified statutory provisions (sections 2 and 4).
• For claims lodged or decisions made prior to commencement, practitioners should verify whether the administrative decision relied on the 2017 SoP and whether any reconsideration or review will engage the new SoP now in force; the instrument itself does not resolve that question.

The instrument itself contains no references to litigation, court decisions, tribunal determinations, or precedents. It does not report any judicial consideration of the SoP, nor does it list cases or disputes that have tested its content. The only legal provenance provided is that the Repatriation Medical Authority determined the Statement of Principles under subsection 196B(3) of the VEA (section 3).

What is therefore knowable from the instrument:

• There is no litigation history recorded in the text. The instrument does not cite any cases or decisions, and no judicial commentary appears in the document.
• The SoP is an administrative medical determination, and historically SoPs are used as medico‑scientific inputs to claim determinations and subsequently may be considered in merits review or judicial review contexts. However, this particular document contains no record of such litigation or review.

What users should do if litigation arises:

• If a claim’s denial or grant is challenged in a merits review body or the courts, parties will need to marshal the evidence required by the SoP (sections 7-11) and any procedural or statutory arguments under the VEA or MRCA. The SoP itself will be an evidentiary/medical standard that the decision maker or reviewing body must consider.
• Because the instrument does not contain interpretive guidance beyond its text, any litigation or review will likely focus on whether the factual material and medical evidence satisfy the specific factors and relationship tests in sections 9 and 10. The SoP’s text will therefore be the primary reference point in such litigation, together with the statutory provisions cited in section 5.

In short, there is no litigation history recorded in the document. Any judicial or tribunal analysis of the SoP will have to be sourced from outside this instrument.

The instrument is short and precise, but it contains several points that are easy for advisers, claimants, or decision makers to misread or overlook. These are practical “gotchas” that arise from the wording and structure of the SoP.

1. Species‑based definition displaces code reliance (section 7(2)-(4)):

   • Although ICD‑10‑AM code B76 is commonly associated with hookworm infection, the SoP explicitly states that in applying the SoP the operative meaning is the species list in subsection 7(2), not the ICD code (section 7(4) and note). Relying solely on a B76 coding entry in medical records without addressing species/form could leave a claim short of the SoP’s definitional requirement.

2. Extraintestinal forms included , but clinical forms matter (section 7(2)(2) and note):

   • The SoP explicitly includes extraintestinal hookworm infection (cutaneous larva migrans) as within the disease concept (section 7(2)(2) and Note 2). Medical reports should therefore ensure that the claimed clinical manifestation is linked to one of the species listed; cutaneous larva migrans commonly involves zoonotic species identified in the SoP (Note 2).

3. Precise species list , limited by the instrument’s wording (section 7(2)(1)):

   • The SoP lists eight specific species. If clinical evidence attributes infection to a different species, that may fall outside the SoP’s definition. Parties relying on generic references to “hookworm” must ensure species identification or clinical linkage to a species in the list.

4. Temporal limit applies to exposure factors only (section 9(1) end):

   • The six‑year limit is attached to the enumerated exposure mechanisms in section 9(1). It is not stated as applying to the inability‑to‑obtain‑appropriate‑clinical‑management factor in section 9(2). Practitioners should not assume the six‑year window covers all possible factors; the text separates the two alternatives.

5. Narrow application of the clinical‑management factor (section 10(2)):

   • Section 10(2) restricts the section 9(2) inability‑to‑obtain‑management factor so that it applies only where the infection was suffered or contracted before or during (but did not arise out of) relevant service. That means if the infection actually arose out of relevant service, inability to obtain management during that service will not, under this provision, operate as the standalone factor described in section 9(2). The wording is intricate and can invert intuitive assumptions about access to care during service periods.

Compliance in this context means preparing, filing, or adjudicating claims for hookworm infection or death from hookworm infection so that they satisfy the medical nexus requirements articulated in the SoP. The instrument sets out what must be established, so compliance is about assembling the appropriate factual and medical material and ensuring that decision makers address the SoP’s elements. The steps below are grounded in the instrument’s text.

1. Confirm that the claim falls within the SoP’s application:

   • Verify that the claim is within the scope of section 120B of the VEA or section 339 of the MRCA (section 5). Confirm the claimant’s type of service meets the Schedule 1 definition of “relevant service” (Schedule 1). If the person’s service is not within those categories, this SoP will not apply to their claim.

2. Establish that the condition is one of the defined hookworm infections:

   • Ensure the medical diagnosis aligns with the species list in subsection 7(2) (Necator americanus; Ancylostoma duodenale; Ancylostoma ceylanicum; Ancylostoma caninum; Ancylostoma braziliense; Ancylostoma tubaeforme; Uncinaria stenocephela; Bunostomum phlebotomum) and that the clinical form (intestinal or extraintestinal/cutaneous larva migrans) is addressed (section 7(2)(1)-(2) and notes). Because the SoP displaces reliance on ICD‑10‑AM code B76 for definitional purposes, reports should not rely solely on coding (section 7(4) and note).

3. For death claims, document contribution to a terminal event:

   • For a death to be within the SoP, the hookworm infection must have contributed to a terminal event or condition as defined in Schedule 1 (section 7(3); Schedule 1). Medical evidence should tie the infection to a proximate or ultimate cause of death, or to one of the enumerated terminal events (e.g. pneumonia, respiratory failure).

4. Satisfy at least one of the section 9 factors and show relation to relevant service:

   • Prepare evidence for one of the following, and show that the factor is related to the claimant’s relevant service (sections 9 and 10(1)): a. Exposure within six years before clinical onset by way of:
     • contact with soil or sand contaminated with larvae (section 9(1)(a));
     • contact with human or animal faeces contaminated with larvae (section 9(1)(b));
     • ingestion of food, drink or dust contaminated with larvae (section 9(1)(c));