Statement of Principles concerning strongyloidiasis (Reasonable Hypothesis) (No. 63 of 2019)

This instrument is a legislative determination known as a Statement of Principles (SoP) made under subsection 196B(2) of the Veterans’ Entitlements Act 1986 (VEA). It replaces the earlier SoP concerning strongyloidiasis (No. 88 of 2010) and sets out the minimum factors that must exist before a reasonable hypothesis can be raised connecting strongyloidiasis, or death from strongyloidiasis, with a person’s relevant service under the VEA or the Military Rehabilitation and Compensation Act 2004 (MRCA). In practical terms, the SoP operates as a binding evidentiary standard for decision‑makers in the Department of Veterans’ Affairs, the Repatriation Commission, the Military Rehabilitation and Compensation Commission and the Administrative Appeals Tribunal when assessing claims for compensation or benefits.

The instrument does not create new offences, impose taxes or regulate commercial activity. Instead, it establishes a deterministic checklist of six causal pathways. A claimant must satisfy at least one of the factors listed in section 9, and that factor must be related to the person’s relevant service as defined in the Schedule 1 - Dictionary (operational service, peacekeeping service, hazardous service, British nuclear test defence service under the VEA, or warlike or non‑warlike service under the MRCA). The SoP also addresses aggravation: factors 9(4), 9(5) and 9(6) apply only to material contribution to or aggravation of strongyloidiasis where the disease was suffered or contracted before or during (but did not arise out of) the person’s relevant service. This distinguishes between initial infection and later worsening.

The instrument begins with definitions: the disease “strongyloidiasis” means an infection with the parasitic roundworm Strongyloides stercoralis, capable of indefinite autoinfection without further environmental exposure. Death from strongyloidiasis is expressly included, encompassing any terminal event (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) contributed to by the strongyloidiasis. The Repatriation Medical Authority (RMA) has stated in section 8 that sound medical‑scientific evidence indicates that the disease and death from it can be related to relevant service. This finding is the legal basis for the SoP, but it is a claim by the RMA and not independently proved in the instrument.

The SoP also includes a “telescoping” provision in section 11: where a factor in section 9 refers to an injury or disease covered by another SoP (for example, “immunosuppressive drug” might link to cancer or renal disease factors), that other SoP applies from time to time. This prevents the need to replicate full disease definitions across multiple instruments but adds complexity for practitioners who must cross‑reference other SoPs.

From a compliance‑burden perspective, the SoP reduces the range of evidence a claimant must produce. Instead of proving causation on the balance of probabilities, the claimant need only raise a reasonable hypothesis by pointing to one of the six prescribed factors and its connection to service. That lower threshold reduces the evidentiary cost for the individual but shifts the analytical burden onto the decision‑maker to determine whether the factor exists and the relationship to service is established. The replaced 2010 SoP is repealed in full, meaning all existing claims not yet finally determined must be reassessed under this version if the claim is still alive. The repeal creates a brief period of uncertainty for claims lodged between the old and new instruments, though the commencement date of 22 July 2019 is clear.

The instrument also implicitly constrains the discretion of decision‑makers. The RMA has determined the exclusive list of factors; a decision‑maker cannot accept a reasonable hypothesis based on a factor not listed, no matter how logically plausible, unless it falls within an existing factor’s interpretation. This lock‑in effect is intended to promote consistency across thousands of claims, but it also means that a veteran with strongyloidiasis from a novel exposure route (not prisoner of war, not soil contact, not transplant, not immunosuppression, not alcohol use, not inability to obtain clinical management) would fail at the threshold, even if a medical expert believed service was a cause. The trade‑off is administrative efficiency against potential under‑compensation of meritorious claims.

The SoP revolves around the concept of a “reasonable hypothesis” as distinct from proof on the balance of probabilities. This standard, embedded in sections 120 and 120A of the VEA, is a lower evidentiary threshold. A reasonable hypothesis is one that is plausible, not fanciful or impossible, and is consistent with the known medical facts. The RMA’s role under section 196B(2) is to determine the factors that can support such a hypothesis; the SoP then becomes the binding checklist. The instrument itself does not define “reasonable hypothesis” - that is left to case law - but it operationalises it by listing conditions that the RMA considers grounded in sound medical‑scientific evidence.

The central disease concept is strongyloidiasis. The instrument goes beyond the ICD‑10‑AM code B78 by adding a precise biological definition: infection with Strongyloides stercoralis. The notes explain that the parasite can replicate inside the body indefinitely via an autoinfective cycle, meaning a single exposure can produce lifelong infection without re‑exposure. This feature has important implications for service connection: a veteran infected during service may not show symptoms until decades later. The SoP does not require that the infection be clinically apparent at the time of service; only that the factor (e.g., cutaneous contact with larvae) occurred before clinical onset. Clinical onset can occur many years after service. This creates a temporal gap that may be difficult to prove, but the SoP does not specify a maximum interval.

Another key concept is the distinction between “clinical onset” and “clinical worsening”. Factors 9(1), 9(2) and 9(3) are tied to the clinical onset of strongyloidiasis. Factors 9(4) (immunocompromised state as specified), 9(5) (alcohol use disorder) and 9(6) (inability to obtain appropriate clinical management) are tied to the time of clinical worsening. This means those three factors cannot establish entitlement for a person who never had the disease before service or who developed the disease during service; they only apply where the disease was already present and is aggravated after service. Section 10(2) reinforces this: factors 9(4) to 9(6) apply only to material contribution to or aggravation of strongyloidiasis where the person’s strongyloidiasis was suffered or contracted before or during (but did not arise out of) the person’s relevant service. This is a crucial limitation that practitioners must watch.

The concept of “immunocompromised state as specified” is defined in the Dictionary with six sub‑categories: treatment with an immunosuppressive drug; haematological or solid organ malignancy; chronic renal failure; HIV infection; severe malnutrition; or solid organ, stem cell or bone marrow transplantation. Chronic renal failure itself has a three‑pronged definition: a glomerular filtration rate below 15 mL/min/1.73 m² for at least three months; need for renal replacement therapy; or undergoing chronic dialysis. Immunosuppressive drug is defined broadly as a drug or agent resulting in substantial suppression of immune responses, with non‑exhaustive examples including chemotherapy agents, corticosteroids (other than inhaled or topical), anti‑rejection drugs and tumour necrosis factor‑α inhibitors. The term “severe malnutrition” is not further defined, opening room for interpretation.

The primary class of persons affected are veterans, members of the Peacekeeping Forces and members of the Forces under the VEA, and members under the MRCA, as well as their dependants who claim compensation or benefits in respect of strongyloidiasis or death from strongyloidiasis. The instrument applies to all claims to which section 120A of the VEA or section 338 of the MRCA applies. This includes initial liability claims, claims for increase, and claims for dependant’s benefits. The SoP does not apply to claims under the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988 or other common‑law actions, unless those schemes incorporate the SoP by reference.

Decision‑makers within the Department of Veterans’ Affairs, the Repatriation Commission, the Military Rehabilitation and Compensation Commission and the Administrative Appeals Tribunal are directly affected. They must apply the SoP as a binding template. Any decision that accepts a reasonable hypothesis must find at least one factor satisfied and that the factor is related to service. The SoP constrains their discretion: they cannot accept a hypothesis based on a factor outside the list unless it falls within an existing factor’s scope. This reduces the time spent on reasoning but also creates rigidity. If a new exposure route becomes medically recognised, the RMA must issue an amending SoP before it can be considered.

Medical practitioners and expert witnesses are indirectly affected. They will be asked to provide reports addressing whether the claimant’s strongyloidiasis is infection with Strongyloides stercoralis, whether a specific factor (e.g., cutaneous contact with larvae) occurred before clinical onset, and whether the factor is related to service. The definitions of immunocompromised state and immunosuppressive drug require medical judgment. The term “severe malnutrition” might require a dietitian’s assessment. The lack of a definition for “inability to obtain appropriate clinical management” complicates expert evidence; a doctor may be asked to opine on what constitutes appropriate management and whether service prevented it.

Legal practitioners and advocates must understand the nuances of onset versus worsening. Mis‑identifying which limb applies can sink a claim. They also need to keep track of the repealed 2010 SoP for claims that may have been lodged and finally determined before 22 July 2019, though section 5 states the instrument applies to a claim to which section 120A or section 338 applies - which likely catches any claim not finally determined at commencement. The repeal provision means unresolved claims under the old SoP are now governed by the new one, potentially changing the factors available.

The instrument does not impose duties in the usual sense of penal laws. Instead, it confers rights on claimants and duties on decision‑makers. The central duty is on the decision‑maker (the Repatriation Commission, the MRCC or the Tribunal) to recognise a reasonable hypothesis connecting strongyloidiasis or death to service if at least one factor in section 9 exists and that factor is related to the person’s relevant service. This duty arises from sections 120 and 120A of the VEA, as operationalised by the SoP. The decision‑maker does not have discretion to add additional factors or to disregard a factor listed.

The right of the claimant is to have their claim assessed in accordance with the SoP. If the claimant satisfies a factor, they are entitled to the benefit of the reasonable hypothesis standard, meaning the decision‑maker must then apply the onus provisions of the VEA. If the decision‑maker finds a factor not made out, the claimant has a right to seek review internally or at the Tribunal, challenging the factual findings or the interpretation of the factor definitions.

A notable duty relates to factor 9(6): inability to obtain appropriate clinical management for strongyloidiasis. This factor imposes an implicit obligation on the veteran’s service to provide reasonable clinical management. If the service fails to do so, and this failure is related to service, the claimant may succeed. This is not a duty directly enforceable by the claimant; it operates only as a pathway to compensation. It creates an incentive for the Department to ensure clinical management is available, because failure may increase compensation liability.

The duty to provide evidence lies with the claimant. The SoP does not shift the burden of proof; the claimant must point to material that raises the existence of a factor and its relationship to service. The decision‑maker must then decide whether the material supports a reasonable hypothesis. The SoP does not specify what evidence is sufficient, leaving that to general administrative law principles.

The RMA has a continuing duty under the VEA to keep SoPs under review and to revoke or amend them when the medical‑scientific evidence changes. This instrument does not create a private right to force an amendment.

The right of a claimant to rely on the “telescoping” provision in section 11 should not be overlooked. If a factor refers to an injury or disease covered by another SoP, the claimant can incorporate that SoP’s factors into the claim. For example, if the immunocompromised state is said to arise from a haematological malignancy, the SoP for that malignancy (if one exists) will apply. This can expand the available pathways.

This instrument contains no penalty provisions. It is not a penal or regulatory instrument. Enforcement mechanisms are found in the enabling Acts. False or misleading statements made in connection with a claim under the VEA may attract penalties under section 137 of the VEA (100 penalty units or imprisonment for 12 months) or under the Criminal Code (section 134.1 for obtaining a financial advantage by deception). The SoP itself does not create any offence.

However, the instrument operates as a gatekeeper. If a decision‑maker fails to apply the SoP correctly, the claimant can enforce their rights through the merits review process (internal review and the Administrative Appeals Tribunal) and ultimately the Federal Court on a question of law. There is no specific “enforcement” body for the SoP; it is enforced through administrative law remedies.

The RMA does not have an enforcement role. It issues SoPs and revokes them, but does not monitor compliance by decision‑makers. Compliance is ensured by the possibility of a successful appeal if the decision‑maker misapplies the SoP.

The Commonwealth Ombudsman could investigate complaints about systemic failures to apply SoPs, but that is not a penalty process.

Economic incentives for non‑compliance are limited. Decision‑makers are public servants who face no personal financial penalty for errors; the risk is adverse Tribunal or court decisions that may require reconsideration, causing delay and administrative cost. Claimants, by contrast, have strong incentives to ensure the SoP is correctly applied, because error can mean loss of entitlement worth many thousands of dollars. The asymmetry of information and resources means claimants may struggle to detect misapplication unless they have legal representation.

The repeal of the 2010 SoP does not impose any penalty for past compliance; it simply supersedes it.

This instrument is made under subsection 196B(2) of the VEA. It interacts most directly with sections 120 and 120A of that Act, which establish the reasonable hypothesis standard. The SoP does not replace or modify those sections; it merely elaborates on the factors that can support a hypothesis. The VEA also contains sections 119 (liberal interpretation) and 120B (which formerly required the RMA to make SoPs; now the requirement is for the RMA to keep them in force). The SoP must be read in conjunction with the VEA, not separately.

The SoP also applies to claims under the MRCA by virtue of section 338 of that Act, which imports the VEA’s SoP regime. The MRCA itself has its own definitions of “warlike service” and “non‑warlike service” (defined in the Dictionary under “relevant service”). The two Acts operate in parallel, and the SoP applies consistently to both, reducing cognitive load for decision‑makers.

Section 11 of the SoP creates interaction with other SoPs. If a factor refers to an injury or disease covered by another SoP (e.g., chronic renal failure, or a haematological malignancy), that other SoP applies as in force from time to time. This means a practitioner must locate the current version of that SoP, not necessarily the one in force at the time of the strongyloidiasis claim. This can create a moving target if the RMA amends the underlying SoP while the claim is pending.

The Schedules of the VEA and MRCA define how service is categorised. The SoP’s definition of “relevant service” is drawn from those Acts. It does not include peacetime service under the VEA (which is not operational, peacekeeping, hazardous or British nuclear test defence service) or warlike/non‑warlike service under the MRCA only. Claims based on peacetime service under the VEA must rely on other provisions (section 120(4) standard), and this SoP does not apply to those claims.

The instrument also interacts with the Evidence Act 1995 (Cth) to the extent that the Tribunal follows its own rules of evidence. The SoP is not a piece of evidence but a legislative instrument that the Tribunal must apply. The ICD‑10‑AM code referenced in section 7(4) is a copyright document of the Independent Hospital Pricing Authority. Its use is mandatory for classification, but the SoP explicitly states that the meaning of strongyloidiasis is that given in subsection (2), not the ICD code. This avoids any interpretive conflict if the ICD later changes its code.

There is no interaction with state or territory workers’ compensation laws, unless a Commonwealth employee also pursues a state claim. But the SoP does not create any offset or bar to other claims. The interaction with private insurance is negligible, as strongyloidiasis claims would rarely be covered by private health insurance for a compensable condition.

The instrument records that it repeals the Statement of Principles concerning strongyloidiasis No. 88 of 2010 (F2010L02844). That is the only prior SoP for this condition under subsection 196B(2). The instrument was made on 21 June 2019 and commenced on 22 July 2019. No amending instruments are listed in the source, and the text shows no changes to itself after enactment.

The RMA may from time to time revoke or amend SoPs under section 196C of the VEA. As of the instrument’s date, no amendments had been made. The source does not indicate any subsequent amendments, but practitioners should check the Federal Register of Legislation for any later instruments. The subject matter (strongyloidiasis) is a relatively stable disease; major changes would likely occur only if new risk factors become medically established (e.g., other immunosuppressive conditions or environmental exposures). The 2010 version was replaced because the RMA updated the factor list, adding the ability to rely on inability to obtain clinical management and clarifying immunocompromised state definitions.

The economic significance of an amendment is that it can change eligibility mid‑stream for unresolved claims. The repeal provision means any claim decided under the old SoP but not finally determined (still under review) must be assessed under the new version. This increases uncertainty for claimants who may have structured their evidence around the old factors. For decision‑makers, it requires retraining and updated templates.

The source document provides no litigation history. It does not cite any court or tribunal decisions. This is standard for an SoP; the RMA does not include litigation summaries. However, the instrument will be applied in a large volume of administrative decisions, many of which are likely to be litigated in the AAT and Federal Court. The most common litigation issues are: whether a factor is “related to” service, the interpretation of “clinical onset” versus “clinical worsening”, and the scope of “inability to obtain appropriate clinical management”.

Because we must ground all claims in the source, we cannot speculate about specific cases. We can state that the SoP itself does not mention any litigation. Its predecessor (No. 88 of 2010) may have been litigated, but that is not in the source. The absence of citation does not mean no litigation exists; it means the RMA did not incorporate it.

The practical implication is that the SoP is relatively new (2019) and will accumulate case law over time. Until then, decision‑makers must interpret the text of the SoP without binding precedent on this particular version. The earlier version’s case law may be persuasive but not binding.

The SoP is subject to judicial review under the Administrative Decisions (Judicial Review) Act 1977 (Cth) and under section 39B of the Judiciary Act 1903 (Cth). A claimant could challenge the SoP itself if they argue it fails to include a factor that sound medical‑scientific evidence supports, but the threshold for such a challenge is high and would likely require direct evidence before the RMA.

Several provisions in this SoP can trip up practitioners and claimants. First is the onset‑worsening distinction. Many claimants will attempt to use factor 9(4) (immunocompromised state) or 9(5) (alcohol use disorder) to establish initial entitlement, not realising these factors only apply to clinical worsening after the disease already existed. If a veteran developed strongyloidiasis during service and later became immunosuppressed, the immunosuppression cannot be used to support a claim for the initial disease; the claim must rely on factors 9(1), 9(2) or 9(3) for onset. Only if the disease pre‑existed service or was contracted before service can the immunocompromised state factor be used to show aggravation. The precise wording of section 9(4) “at the time of the clinical worsening” and section 10(2) is critical.

Second, factor 9(1) “being a prisoner of war before the clinical onset of strongyloidiasis” does not require proof that the prisoner‑of‑war conditions caused the infection; it is a proxy factor. The SoP presumes that POW status raises a reasonable hypothesis regardless of whether the veteran actually contacted Strongyloides stercoralis. This is a generous provision but one that can be overlooked if the veteran was a POW but the claim is framed around soil contact instead.

Third, factor 9(6) “inability to obtain appropriate clinical management for strongyloidiasis” is vague and not defined. It raises questions: is the inability assessed objectively or subjectively? Must the clinical management have been available in the veteran’s location? Could the veteran have obtained treatment privately or from a non‑Defence provider? The factor only applies to clinical worsening, meaning the veteran must already have the disease and the inability to manage it caused the worsening. This factor could be used in cases where a veteran in a remote posting could not access anti‑helminthic drugs, but it requires both evidence of non‑availability and evidence that the disease worsened as a result.

Fourth, the definition of “immunocompromised state as specified” includes “severe malnutrition” without a quantitative threshold. Malnutrition is common in certain service environments (captivity, prolonged field operations), but proving “severe” requires medical assessment. The lack of a clear metric invites inconsistent decisions. A decision‑maker might adopt a body mass index threshold or a clinical diagnosis, but the SoP does not prescribe one, increasing discretion risk.

Fifth, the definition of “immunosuppressive drug” specifically excludes inhaled or topical corticosteroids. This means a veteran using a steroid inhaler for asthma cannot use that as a basis for immunocompromise under this factor. However, systemic corticosteroids (oral or injectable) count. The examples list tumour necrosis factor‑α inhibitors, which are used for arthritis and inflammatory bowel disease - veterans with those conditions may have a dual SoP issue.

Compliance is not about businesses or individuals following rules to avoid penalties. Instead, “compliance” here means ensuring that claims are properly assessed and that decision‑makers correctly apply the SoP to avoid errors leading to successful appeals and wasted administrative resources.

For a claimant, compliance means gathering evidence that supports at least one of the six factors and demonstrates a relationship to relevant service. The first step is to obtain a medical diagnosis confirming infection with Strongyloides stercoralis. Serological or stool testing should be documented. The diagnosis must meet the definition in subsection 7(2). If the claim is for death from strongyloidiasis, medical evidence must show that the strongyloidiasis contributed to a terminal event such as pneumonia or respiratory failure.

Second, identify the service period and type of service (operational, peacekeeping, etc.). Only “relevant service” as defined qualifies. If the service is peacetime, the SoP cannot be used and the claimant must rely on the general standard under section 120(4) of the VEA.

Third, identify the appropriate factor. For factor 9(1), obtain prisoner‑of‑war documentation. For factor 9(2), obtain evidence of cutaneous or mucosal contact with moist soil, sediment or mud contaminated with human or animal faeces during service. Service records showing tropical deployment, infantry patrols, living conditions, or lack of sanitation facilities are useful. Lay statements from the veteran or fellow soldiers can corroborate. For factor 9(3), obtain transplant records showing the organ donor had Strongyloides infection. For factor 9(4), medical records showing immunosuppressive drug treatment, malignancy, chronic renal failure, HIV, severe malnutrition or transplant at the time of clinical worsening are required. For factor 9(5), evidence of alcohol use disorder diagnosis (from medical records or validated screening) at the time of worsening. For factor 9(6), evidence that clinical management was not available - this could include Defence health policies, postings to remote bases, or lack of supply of ivermectin or albendazole. Management must be “appropriate” according to current medical standards.

Fourth, if using factor 9(4) to 9(6), ensure the disease was contracted or suffered before or during service but not arising out of that service. This may require a separate analysis. If the disease arose out of service, those factors should not be used; instead rely on factors 9(1) to 9(3) for the initial claim.

Fifth, check whether any factor involves a condition covered by another SoP (e.g., chronic renal failure or haematological malignancy). If so, locate and apply the relevant SoP for that condition. The other SoP may have its own factors and definitions.