VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_12-vv-00232
Package ID: USCOURTS-cofc-1_12-vv-00232
Petitioner: Elijah McLeod
Filed: 2012-04-10
Decided: 2015-03-19
Vaccine: Tdap
Vaccination date: 2011-04-20
Condition: multiple sclerosis
Outcome: denied
Award amount USD: 

AI-assisted case summary:
On April 10, 2012, Jacqueline S. Hunt, as legal guardian for minor Elijah McLeod, filed a petition for compensation under the National Childhood Vaccine Injury Act. The petition alleged that Tdap, varicella, and meningococcal vaccines administered on April 20, 2011, caused Elijah to develop acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS), or significantly aggravated a pre-existing condition. The respondent, the Secretary of Health and Human Services, disagreed with the petitioner's claims. Petitioner was represented by Daniel Pfeifer of Pfeifer, Morgan & Stesiak, and respondent was represented by Tara J. Kilfoyle and Heather L. Pearlman from the U.S. Department of Justice. Special Master Christian J. Moran presided over the case.

Elijah McLeod, born in 1999, began experiencing symptoms prior to vaccination. Reports indicated that in the fall of 2010, he started using his right hand more than his left, and in February 2011, he began experiencing double vision. He did not seek medical attention for these issues at the time. Following the April 20, 2011 vaccinations, Elijah became ill, experiencing vomiting, dizziness, and unsteadiness. He was seen in the emergency room on April 21 and April 22, 2011, where initial assessments noted a localized reaction and later revealed areas of hypodensity in his brain via CT scan. He was hospitalized, and an MRI on April 23, 2011, showed abnormalities interpreted as likely ADEM, with multiple sclerosis considered less likely. A lumbar puncture revealed oligoclonal bands in his cerebrospinal fluid (CSF). He was treated with steroids and physical therapy and discharged on April 29, 2011, with a diagnosis consistent with ADEM, though MS remained a differential diagnosis.

Subsequent MRIs and clinical evaluations in May and June 2011 showed evolving demyelinating lesions. By August 2011, an MRI showed progression of white matter disease with more lesions, leading Dr. David Mattson, Elijah's treating neurologist, to declare a diagnosis of multiple sclerosis. Dr. Mattson opined that the vaccinations caused Elijah's ADEM and MS. The Secretary retained Dr. Subramanian Sriram as an expert, who opined that Elijah's symptoms predated the vaccinations and that the vaccines did not cause or worsen his MS. Dr. Sriram noted that the oligoclonal bands found in Elijah's CSF 48 hours post-vaccination indicated that his MS likely predated the vaccinations, as antibody production typically takes longer.

The Special Master found that Elijah had experienced clinical symptoms of multiple sclerosis, including hand weakness and double vision, prior to the vaccinations. The presence of oligoclonal bands in his CSF also indicated immune dysregulation before vaccination. Consequently, the Special Master determined that the claim could only proceed as one of significant aggravation, not new onset causation. The Special Master further found that the petitioner failed to prove by a preponderance of the evidence that the vaccines significantly aggravated Elijah's multiple sclerosis. The medical theories presented by Dr. Mattson (molecular mimicry and bystander activation) were found unpersuasive, and epidemiological studies did not support a link between the vaccines and MS. The Special Master also found that the timing of symptom onset was not medically acceptable to infer causation, as the earliest neurological symptoms appeared within one day of vaccination, which was deemed too soon for an immune-mediated process to develop, even with pre-existing immune dysregulation.

On review, the Court of Federal Claims, Judge Lydia Kay Griggsby presiding, agreed that the Special Master had committed some procedural errors in the analysis of the causation-in-fact claim, specifically by making a preliminary diagnosis of pre-existing MS before fully applying the Althen framework and by not fully considering all evidence related to ADEM. However, the Court found these errors to be harmless because, even with a corrected analysis, the petitioner had not met her burden of proof for either causation-in-fact or significant aggravation. The Court affirmed the Special Master's denial of compensation.

Subsequently, on October 14, 2015, Special Master Christian J. Moran issued a decision regarding attorneys' fees and costs. Although compensation was denied, the petition was deemed to have been brought in good faith with a reasonable basis. Petitioner's counsel, Pfeifer Morgan & Stesiak, sought $92,500.00 for attorneys' fees and costs, an amount to which the respondent did not object. The Special Master awarded this amount.

Theory of causation field:
Petitioner Jacqueline S. Hunt alleged that Elijah McLeod, a minor, received Tdap, varicella, and meningococcal vaccines on April 20, 2011, and that these vaccines caused him to develop acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS), or significantly aggravated a pre-existing condition. Petitioner's expert, Dr. David Mattson, opined that the vaccines caused ADEM and MS through theories of molecular mimicry and bystander activation, and that the onset of neurological symptoms occurred within two days of vaccination. Respondent's expert, Dr. Subramanian Sriram, opined that Elijah's symptoms, including hand weakness and double vision, along with oligoclonal bands in his CSF, indicated that MS predated the vaccinations. Dr. Sriram stated that the biological process for vaccine-induced immune attack on the central nervous system typically takes at least five days, making a one-day onset medically implausible. The Special Master found that Elijah had pre-existing clinical symptoms and laboratory evidence of MS before vaccination, thus limiting the claim to significant aggravation. The Special Master denied compensation, finding that petitioner failed to prove by a preponderance of the evidence that the vaccines caused a significant aggravation of MS, citing unpersuasive medical theories, lack of epidemiological support, and an unacceptable temporal relationship between vaccination and symptom onset. The Court of Federal Claims affirmed the denial, agreeing that petitioner failed to prove causation-in-fact or significant aggravation, despite finding some procedural errors in the Special Master's analysis. Petitioner's counsel was awarded $92,500.00 in attorneys' fees and costs due to the good faith and reasonable basis of the petition.

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_12-vv-00232-0
Date issued/filed: 2015-03-19
Pages: 39
Docket text: PUBLIC DECISION (Originally filed: 2/23/2015) regarding 66 DECISION of Special Master. Signed by Special Master Christian J. Moran. (tpj) Copy to parties.
--------------------------------------------------------------------------------
Case 1:12-vv-00232-LKG Document 67 Filed 03/19/15 Page 1 of 39
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
* * * * * * * * * * * * * * * * * * * * *
JACQUELINE S. HUNT, *
legal guardian of a minor child, * No. 12-232V
ELIJAH MCLEOD, * Special Master Christian J. Moran
*
Petitioner, * Filed: February 23, 2015
*
*
v. * Entitlement; Varicella Vaccine;
* Tetanus-Diphtheria Acellular
* Pertussis (“Tdap”) Vaccine;
SECRETARY OF HEALTH * Pneumococcal Vaccine; Multiple
AND HUMAN SERVICES, * Sclerosis; Acute Disseminated
* Encephalomyelitis (ADEM);
Respondent. * Significant Aggravation; Timing.
* * * * * * * * * * * * * * * * * * * * *
Daniel Pfeifer, Pfeifer, Morgan & Stesiak, South Bend, IN, for petitioner;
Tara J. Kilfoyle and Heather L. Pearlman, United States Dep’t of Justice,
Washington, DC, for respondent.
PUBLISHED DECISION DENYING COMPENSATION1
Elijah McLeod, now age 15 years, suffers from multiple sclerosis. Multiple
sclerosis impairs the functioning of the central nervous system, causing the person
difficulty with tasks such as walking. The etiology of multiple sclerosis is not
known. Scientists generally believe that the body’s immune system, which usually
attacks invaders such as viruses and bacteria, aberrantly turns on itself and attacks
the host’s central nervous system. What prompts this attack is not known.
1 The E-Government Act of 2002, Pub. L. No. 107-347, 116 Stat. 2899, 2913 (Dec. 17,
2002), requires that the Court post this decision on its website. Pursuant to Vaccine Rule 18(b),
the parties have 14 days to file a motion proposing redaction of medical information or other
information described in 42 U.S.C. § 300aa-12(d)(4). Any redactions ordered by the special
master will appear in the document posted on the website.

Case 1:12-vv-00232-LKG Document 67 Filed 03/19/15 Page 2 of 39
In this case, the basic claim is that vaccinations that Elijah received are
responsible for his multiple sclerosis. Recovery is sought via two different causes
of action. First, there is a claim that the vaccinations caused Elijah to suffer
multiple sclerosis. This new onset theory is premised on an assertion that Elijah
had not experienced any symptoms of multiple sclerosis before the vaccinations.
As an alternative, the petitioner also alleges that if Elijah were suffering from
multiple sclerosis before the vaccinations, then the claim is that the vaccinations
significantly aggravated his multiple sclerosis.
Jacqueline S. Hunt, the petitioner,2 has presented the opinions of David
Mattson. Many of Dr. Mattson’s patients suffer from multiple sclerosis and, in
fact, Elijah is one of his patients. Dr. Mattson opined that the vaccinations harmed
Elijah in either of the two ways described above.
The Secretary disagreed with this opinion and retained Subramanian Sriram.
Like Dr. Mattson, Dr. Sriram has experience in treating patients with multiple
sclerosis. Dr. Sriram’s opinion was that there was not persuasive evidence linking
the vaccinations to Elijah’s multiple sclerosis. In Dr. Sriram’s view, Elijah had
problems in his central nervous system prior to the administration of the allegedly
causal vaccinations that Dr. Sriram retrospectively recognized as manifestations of
multiple sclerosis. Hence, the vaccinations did not cause the multiple sclerosis.
Furthermore, the vaccinations did not make the multiple sclerosis worse than it
would have been otherwise.
Dr. Sriram’s opinion on the viability of the new-onset claim is more
persuasive. He accounted for reports of Elijah’s problems before vaccination to
show that Elijah’s multiple sclerosis probably pre-dated the vaccinations.
Conversely, Dr. Mattson’s attempts to dismiss Elijah’s double vision and dominant
hand weakness were not persuasive. Thus, Elijah’s claim is actually a claim of
significant aggravation, not a new onset claim.
Under a significant aggravation theory, a petitioner must establish six
elements. Although Dr. Mattson’s opinions addressed all six topics, his opinions
lacked persuasiveness in several respects. The theory that vaccinations can worsen
2 Originally, the named petitioner was Tomika McLeod, Elijah’s mother. During this
litigation, it was learned that Elijah’s legal guardian was his grandmother, Jacqueline S. Hunt. A
January 10, 2014 order corrected the caption, designating Ms. Hunt as the petitioner. For
simplicity, this decision refers to Ms. Hunt as the petitioner regardless of whether Ms. McLeod
or Ms. Hunt was initially the petitioner.
2

Case 1:12-vv-00232-LKG Document 67 Filed 03/19/15 Page 3 of 39
multiple sclerosis is contrary to an unrebutted epidemiologic study on this precise
question. Additionally, Dr. Mattson made several assumptions and drew
attenuated inferences that weakened the value of his opinion that relevant vaccines
can cause multiple sclerosis. If a relevant vaccine could cause multiple sclerosis,
then the proposed biologic process would take at least three days. However, Dr.
Sriram persuasively showed that the contemporaneously created medical records
establish that Elijah was suffering overt neurologic problems within one day of
vaccination. This swiftness is inconsistent with the allegation that the vaccinations
worsened Elijah’s multiple sclerosis.
In short, Ms. Hunt has failed to present a preponderant case that the
vaccinations caused Elijah to be worse than he would have been but for the
vaccinations. She has shown that Elijah was worse after the vaccinations but she
has not shown Elijah was worse because of the vaccinations. Because her proof is
lacking, she is not entitled to compensation and the Clerk’s Office is directed to
enter judgment in accord with this decision.
I. Facts3
Elijah was born in 1999. Exhibit 1 at 1. As a young boy, Elijah did not have
any lasting health problems according to the records of his pediatrician. See
exhibit 3.
Reports given to his doctors indicate that in the fall of 2010, Elijah started
using his right hand more than his left hand. See exhibit 5 at 11 (Dr. El-Zind);
exhibit 7 at 1 (Dr. Toper); exhibit 12 at 708 (report to physical therapist on June
22, 2011). Dr. Mattson obtained a history that Elijah suffered a small accident
while playing sports, but did not seek any medical attention. Exhibit 10 at 1.
Elijah also testified about this injury. Tr. 257-61.
In February 2011, again according to histories provided later, Elijah started
having double vision. Exhibit 5 at 11 (Dr. El-Zind); exhibit 7 at 1 (Dr. Toper;
3 These facts are not disputed as the parties’ briefs largely track each other. Compare
Pet’r’s Posthr’g Br. at 1-8 with Resp’t’s Posthr’g Br. at 3-8. Although Dr. Mattson and Dr.
Sriram accept the accuracy of records created contemporaneously with the events the records
describe, they reach different conclusions about the significance of some events in Elijah’s
history. Dr. Mattson’s and Dr. Sriram’s interpretations are interspersed throughout the narrative.
3

Case 1:12-vv-00232-LKG Document 67 Filed 03/19/15 Page 4 of 39
exhibit 7 at 53 (Dr. Yoon). Elijah did not see a doctor for his vision problem at
this time.
The experts differed in their views about Elijah’s arm problem and double
vision. Dr. Mattson acknowledged that an inability to use one’s dominant hand
could be a symptom of multiple sclerosis in general. Tr. 105. But, Dr. Mattson did
not see the switch in hand-dominance as a manifestation of multiple sclerosis in
this particular case because of an alternative explanation: Elijah had a sports injury
that may have affected his left hand. Id. at 79-80, 105-06, 245.
Similarly, Dr. Mattson did not give much weight to the later-given reports of
double vision because he was “handicapped by not having any evaluations in real
time.” Tr. 106. In addition, as discussed below, once Elijah’s trouble with double
vision came to light, an ophthalmologist could not confirm the presence of double
vision. Tr. 107, 117. Nevertheless, Dr. Mattson agreed that before the
vaccinations, it was likely that Elijah was suffering from subclinical multiple
sclerosis. Tr. 119.
In contrast, Dr. Sriram stated that the switch in handedness and complaints
of double vision “are telltale signs of some neurologic abnormality.” Tr. 179. Dr.
Sriram went further and declared that “those were [Elijah’s] first events” of
multiple sclerosis. Id. at 180.4
When Elijah was 12, he received a set of vaccines on April 20, 2011.
Specifically, Elijah was administered a dose of the tetanus-diphtheria acellular
pertussis (“Tdap”), varicella, and meningococcal vaccines. Exhibit 2 at 1–3.
The next day, Elijah was sick at school. He vomited and felt dizzy and off-
balance. Exhibit 4 at 3, 12; see also exhibit 19 (affidavit of Ms. McLeod) ¶ 3.
Elijah’s mother took him to the emergency room of Memorial Hospital of South
Bend. Dr. Kavanaugh attended to Elijah in the emergency room. Elijah told Ms.
McLeod about his previous experience of problems with his left arm for the first
time because the current tingling sensation on his face was similar to the tingling
he had felt in his left arm months earlier. Tr. 259-61. Dr. Kavanaugh noted a
4 Dr. Mattson and Dr. Sriram agreed that Elijah could not be diagnosed as suffering from
multiple sclerosis based upon a single event, such as an arm injury. Tr. 80-81 (Dr. Mattson
suggesting that Elijah’s left arm problem might constitute a “clinically isolated syndrome”), 208
(Dr. Sriram stating that the arm problem was Elijah’s first event and the April 22, 2011
presentation was the second event).
4

Case 1:12-vv-00232-LKG Document 67 Filed 03/19/15 Page 5 of 39
small area of redness on Elijah’s left arm as well as mild tenderness and a bit of
warmth. Dr. Kavanaugh also observed some possible slight swelling on the left
side of Elijah’s face. Dr. Kavanaugh reported that Elijah was oriented to person,
place, and time, and appeared to be in no acute distress. Dr. Kavanaugh assessed
Elijah as having a localized reaction to a vaccination. Exhibit 4 at 3. Elijah was
not admitted to the hospital. See exhibit 19 ¶ 3.
Again, Dr. Mattson and Dr. Sriram drew different conclusions from Elijah’s
presentation at the emergency room on April 21, 2011. Dr. Mattson averred that
Elijah’s problems were “really more related to a local injection. . . . [T]here really
was nothing indicating any kind of focal neurologic problem at that point.” Tr. 26.
Dr. Sriram, by contrast, stated that “some of his symptoms were . . . a local
reaction to the injection.” But, Dr. Sriram could also see that “some of them were
clearly neurological.” Tr. 194. The neurological symptoms included dizziness and
unsteadiness in walking. From the observation that Elijah’s face was swollen, Dr.
Sriram reasoned that Elijah’s facial muscles were weak and not functioning
normally. Tr. 193-94, 238. Dr. Mattson did not controvert Dr. Sriram’s basis for
concluding that Elijah had weakness in his facial muscles and said that Dr.
Sriram’s explanation was “certainly a possibility.” Tr. 248.
The following day, April 22, 2011, Elijah was still not feeling well enough
to return to school. Exhibit 19 ¶ 4. Elijah’s grandmother brought him back to the
emergency room where Dr. Kavanaugh saw him again. Exhibit 5 at 15. The chief
complaint was that Elijah was “‘not himself.’” Exhibit 5 at 355. The doctor was
concerned about Elijah’s poor balance and ordered a CT scan of Elijah’s head. Id.
The CT scan identified at least two areas of hypodensity in Elijah’s brain. Id. at
347.
Dr. Mattson recognized that on April 22, 2011, Elijah “was starting to
develop some focal signs or focal symptoms of neurologic dysfunction.” Tr. 28.
To Dr. Sriram, Elijah’s presentation on April 22, 2011, constituted a “second
event” for making a diagnosis of multiple sclerosis. The “first event” preceding
the April 22, 2011 “second event” was the arm weakness and double vision. Tr.
201-02.
Very late in the evening of April 22, 2011, Elijah was admitted to the
pediatric unit of Memorial Hospital. Exhibit 5 at 29. A nurse’s assessment stated
that Elijah was “‘acting like he had a stroke.’” In the neurological history, the
nurse recorded that Elijah had had no previous medical history but, tonight, he was
5

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having numbness on the left side of his face. Id. at 375-76. Very early in the
morning of April 23, 2011, a doctor ordered an MRI to evaluate the abnormality
detected on the CT scan and Elijah’s ataxia. Id. at 28.
At approximately 10:00 AM on April 23, 2011, Dr. Samira El-Zind saw
Elijah for the first time. (Dr. El-Zind has followed Elijah throughout the course of
his illness.) The history Dr. El-Zind obtained is consistent with the history
presented above. Dr. El-Zind stated “when I talked to mom later I understood that
there was some concern about his hand for the past 7 months [as] he is left handed
and he was using the right hand. . . [P]atient also said that he has double vision
that was going on for 2 months.” Exhibit 5 at 11.5 Dr. El-Zind recommended an
MRI, a spinal tap, and an MS panel. She stated that she was “concerned about the
fact that some of the symptoms [have] been there for a while.” Id. at 12.
Dr. El-Zind’s impression on April 23, 2011, was that Elijah had “possible
acute disseminating encephalomyelitis with [a] post-immunization reaction.” Dr.
El-Zind came to this conclusion before any of the tests she ordered (an MRI, spinal
tap, and MS panel) were conducted. Exhibit 5 at 12. In his testimony, Dr. Mattson
discussed that Dr. El-Zind stated, on April 23, 2011, that Elijah may have ADEM.
Tr. 30-31. To Dr. Sriram, Dr. El-Zind’s conclusion was reasonable based upon her
knowledge at that time. When the information about Elijah’s later course is added,
Dr. El-Zind’s “assessment has to change.” Tr. 214.
Elijah had an MRI on April 23, 2011. It identified large areas of abnormal
signals. Allison Lamont, the radiologist who interpreted the MRI, stated that the
abnormalities were “likely related to acute disseminated encephalomyelitis
(ADEM), seen in postvaccination settings. A demyelinating process such as
multiple sclerosis is felt to be much less likely.” Exhibit 5 at 350.6
Dr. Mattson mentioned Dr. Lamont’s diagnosis without adding much. Tr.
32. Dr. Sriram questioned Dr. Lamont’s ability to diagnose ADEM or multiple
5 Dr. El-Zind’s notes tend to be written in lower case letters only. In this decision, the
capitalization is changed without notation.
6 The MRI was performed with and without contrast. “On the postcontrast images,
variable enhancement is demonstrated.” Exhibit 5 at 350. Although the presence of enhanced
lesions could provide some information about the age of the lesions, see W.C. v. Sec'y of Health
& Human Servs., 704 F.3d 1352, 1354 (Fed. Cir. 2013), the enhancements on Elijah’s initial
MRI were not discussed extensively. See Tr. 31-32, 178.
6

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sclerosis because those are clinical entities, but she had neither seen Elijah nor
obtained his history. Tr. 212-13.
Elijah also had a lumbar puncture on April 23, 2011. The test revealed two
or more oligoclonal bands in Elijah’s cerebrospinal fluid. The report stated that
“oligoclonal bands are present in approximately 95 percent of patients with
multiple sclerosis but may also be present in the CSF from patients with... [other
diseases].” Exhibit 5 at 339.
Dr. Mattson opined that the presence of oligoclonal bands was consistent
with a diagnosis of ADEM. They also “increase the risk of going on to be
[multiple sclerosis].” Tr. 34. In contrast, to Dr. Sriram, the presence of
oligoclonal bands meant that Elijah already was suffering from multiple sclerosis.
Tr. 195.
The doctors prescribed high-dose steroids while Elijah remained in the
hospital. While hospitalized, Elijah started physical therapy. His therapist
reported that he was “concerned about writing with his left hand – has bad grip on
pencil. Left fingers feel big and heavy.” Exhibit 5 at 818.
Elijah was discharged on April 29, 2011, and was prescribed prednisone to
taper over the next two weeks. At discharge, Elijah’s diagnosis “seem[ed]
consistent with ADEM; however multiple sclerosis is still in the differential.”
Exhibit 5 at 4.
At the hearing, Dr. Mattson’s testimony about Elijah’s status as of his
discharge at the end of April 2011 was confusing. Dr. Mattson asserted that with
the information available in April 2011, a doctor could not diagnose Elijah as
having multiple sclerosis because Elijah, in Dr. Mattson’s view, had not
experienced two events disseminated in time and space. Tr. 99.7 When pressed to
say whether Elijah could be diagnosed as suffering from multiple sclerosis in April
2011 based upon all the information known through the date of the hearing, Dr.
Mattson seemed to equivocate between saying that Elijah had ADEM, which
became multiple sclerosis, and saying that Elijah always had multiple sclerosis.
Tr. 100-02.
7 Dr. Mattson discounted Elijah’s history of a change in hand dominance and double
vision for reasons explained in the text above. Dr. Mattson considered Elijah’s presentation on
April 22, 2011 to be the first manifestation of neurologic symptoms.
7

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Following his April 2011 hospitalization, Elijah’s first appointment was with
Dr. El-Zind on May 5, 2011. Elijah told her that he was feeling “tingling” in the
left side of his face and in his right fingertips. Elijah also reported that he did not
use his left arm or hand and he felt fatigued if he was doing too much. Dr. El-Zind
reported that Elijah was weaning off of prednisone. She stated that Elijah had
“possible ADEM / MS.” Dr. El-Zind requested another MRI. Exhibit 6 at 7-8.
Elijah’s next appointment was on May 6, 2011, with Ziya Toper, his primary
care physician. Dr. Toper’s history recited that Elijah had weakness in his left
hand for one year and double vision for two months before he was hospitalized.
Because of the possibility of ADEM, Dr. Toper referred Elijah to an
ophthalmologist. Exhibit 7 at 1-2.
Elijah saw an ophthalmologist, Eric Yoon, on May 13, 2011. Dr. Yoon
recorded that Elijah “complains of some double vision intermittently for the past
two months. He states that he does not have any[]more double vision.” Dr. Yoon
gave him a prescription for glasses and recommended a routine examination in one
year. Exhibit 7 at 53. Dr. Mattson asserted that the double vision could have
resolved by the time Elijah saw the ophthalmologist. Tr. 37.
On May 16, 2011, Elijah had his second MRI. The interpreting radiologist,
Pedro A. Miro, compared this MRI to the April 23, 2011 MRI. Dr. Miro did not
note any significant enhancement and identified only a small new lesion. Dr. Miro
stated “the findings are consistent with the patient’s repeated history of acute
disseminated encephalomyelitis.” Exhibit 9 at 232. Dr. Miro added “[a]s per
discussion with Dr. El-Zind[,] the possibility of multiple sclerosis is not
excluded.” Id. at 233.
Dr. Mattson had a slightly different interpretation of the imaging. He was
not convinced that the lesion was new. Tr. 39. But, even if the lesion were new,
Dr. Mattson interpreted the two MRIs (one on April 23, 2011, and the other on
May 16, 2011) as “consistent with that first wave of inflammatory demyelination.”
Tr. 39; accord Tr. 143-44.
That day, Dr. El-Zind reviewed the MRI during an appointment with Elijah.
She also again recorded a history in which “mom said that the symptoms in his left
hand with clumsiness and avoiding to use it in[]spite of being left[]handed [have]
been going on for 7 months. Also 2 months before the hospital admi[ss]ion he had
blurred vision.” Currently, although Elijah’s balance has been better, his legs and
8

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feet still tired easily. Dr. El-Zind recommended admitting him to the hospital for
another course of IVIG. Exhibit 6 at 5-6.
Elijah stayed in Memorial Hospital from May 16, 2011 to May 21, 2011.
Exhibit 9 at 3 (discharge report). Another study of his CSF again revealed
oligoclonal bands, “suggesting multiple sclerosis.” Id. During this hospitalization,
Dr. El-Zind consulted neurologists at Indiana University Hospital, where Dr.
Mattson works. According to an email, Dr. El-Zind told one of Dr. Mattson’s
colleagues that Elijah “had a 7 month history of decreased use of the left arm. He
was treated with steroids, has oligoclonal bands and positive myelin basic protein
and a new lesion on his second MRI.” The email indicates that Dr. El-Zind “is
pretty convinced [Elijah] has MS.” Exhibit 10 at 50.
Some records suggest that doctors at Memorial Hospital were thinking that
Elijah was suffering from multiple sclerosis in May 2011. For example, the
handwritten orders for his discharge state that Elijah was diagnosed with a “MS
flair.” Exhibit 9 at 11, 203.
Dr. Mattson saw Elijah at Indiana University Hospital on June 10, 2011. Dr.
Mattson’s history did not include Elijah’s report of having double vision. Exhibit
26 at 1; Tr. 146. With that addition, Dr. Mattson obtained a history that was
consistent with the information provided above. With respect to Elijah’s trouble
with his left arm since the fall of 2010, Elijah told Dr. Mattson that he “chalked
this up to [an] injury playing football and never sought medical attention for it and
did not tell his mother about it even.” Exhibit 17 at 21. Dr. Mattson was not told
that Elijah was having double vision for two months before his hospitalization.
Dr. Mattson stated that he was being consulted “about a postvaccination
acute disseminated encephalomyelitis, which raises the possible diagnosis of
multiple sclerosis.” Id. In addition to obtaining Elijah’s medical history, Dr.
Mattson examined him. Dr. Mattson recorded that Elijah had a decreased
sensation to touch in his left arm and leg. Elijah also had difficulty walking.
Dr. Mattson reviewed both of Elijah’s MRIs. Dr. Mattson interpreted the
second MRI as showing improvement, such as a lack of enhancement. He was not
convinced that the second MRI showed a new lesion, “but even if there were [a
new lesion], that [new lesion would] still [] be part of a protracted first event of
demyelination in response to his vaccinations.” Id. at 22.
Dr. Mattson considered “the oligoclonal IgG bands in his spinal fluid [to be]
consistent with an acute disseminated encephalomyelitis.” But, Dr. Mattson
9

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recognized that the presence of oligoclonal bands “increases the risk that this will
go on to be multiple sclerosis.” Dr. Mattson “certainly would give him the benefit
of doubt [that] this is a one time postvaccination event.” Id.
For treatment, Dr. Mattson prescribed a medication for headaches and
encouraged Elijah to continue his physical therapy. Dr. Mattson also
recommended another MRI in September 2011, to check whether the lesions had
disappeared. Exhibit 10 at 3.
On June 20, 2011, Elijah saw Dr. El-Zind again. He complained about
problems with his equilibrium and pain in various parts of his body. Dr. El-Zind
recommended a third MRI. Exhibit 6 at 3-4. The report from that MRI stated that
“the number and distribution of the lesions appears stable.” It also stated there
were “three new foci of abnormal enhancement.” The radiologist reported that the
lesions are “nonspecific but consistent with the expected changes of evolving
demyelinating lesions such as can be seen with MS or ADEM.” Exhibit 12 at 251-
52. Elijah remained in the hospital for 5 days. Id. at 3. Dr. El-Zind called Dr.
Mattson regarding this MRI. On June 20, 2011, Dr. Mattson stated he wanted to
see Elijah as soon as possible to start Elijah on Rebif, a medication for pediatric-
onset multiple sclerosis. Exhibit 10 at 47.
Elijah had headaches, body aches, and a stomach ache on August 17, 2011.
When he went to the emergency room, the doctor recognized that Elijah had
problems walking and muscle twitching. Elijah had a fourth MRI on August 18,
2011. This MRI showed a progression of white matter disease with several more
lesions. The radiologist interpreted the results as consistent with multiple sclerosis.
Exhibit 13 at 3-4.
With a copy of his most recent MRI, Elijah returned to see Dr. Mattson on
August 26, 2011. Dr. Mattson stated that “I now feel very comfortable that this
has been declared as multiple sclerosis.” Dr. Mattson prescribed Copaxone.
Exhibit 17 at 5-6; see also Tr. 117 (Dr. Mattson describing Elijah’s presentation in
August 2011 as an “exacerbation of his multiple sclerosis”).
On December 23, 2011, Dr. Mattson saw Elijah for a follow-up. Dr.
Mattson stated that Elijah has had a case of pediatric-onset multiple sclerosis for
“approximately 8 months duration.” Exhibit 24 at 3. Other follow-up
appointments with Dr. Mattson were held on September 4, 2012, and May 14,
2013. Exhibit 43 at 1-3; see also Tr. 97-98 (Dr. Mattson’s estimate that he sees
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Elijah every 6 to 12 months). While taking Copaxone, Elijah has done relatively
well. He has not had any severe flares of his multiple sclerosis.
II. Procedural History
The petition was filed on April 10, 2012, and was originally assigned to a
different special master. Ms. Hunt filed medical records in July 2012. The
material included a nine-paragraph affidavit from Dr. Mattson, who averred that
Elijah’s ADEM and multiple sclerosis were “caused in fact by his vaccinations
received on April 20, 2011.” Exhibit 18 ¶¶ 7-8.
The Secretary reviewed this material in her report, filed pursuant to Vaccine
Rule 4, on August 29, 2012. The Secretary’s assessment forecast the issues that
remained disputed throughout the litigation. The Secretary argued that Elijah did
not suffer from ADEM and that he suffered from only multiple sclerosis. Resp’t’s
Rep. at 10-11. For the multiple sclerosis aspect, the Secretary maintained that Ms.
Hunt had not established that any vaccine caused Elijah’s multiple sclerosis. The
Secretary argued Elijah experienced symptoms of multiple sclerosis before the
vaccination. The Secretary noted that it appeared that Dr. Mattson was not aware
of these symptoms and characterized Dr. Mattson’s affidavit as “conclusory.”
Finally, in a footnote, the Secretary remarked that Ms. Hunt had not alleged that
the vaccinations significantly aggravated Elijah’s pre-existing multiple sclerosis.
A few days after the Secretary filed her report, the case was reassigned to the
undersigned. A status conference was held later that month. In that status
conference, the undersigned suggested that Ms. Hunt file an affidavit regarding
damages and obtain a more comprehensive report from Dr. Mattson.
Ms. Hunt filed a two-page report from Dr. Mattson on December 28, 2012.
He stated that vaccinations can cause ADEM and once a person experiences an
initial episode of ADEM, the person is more vulnerable to having a second attack.
After a second attack, “a diagnosis of multiple sclerosis (MS) can be made.”
Exhibit 26 at 1.
With respect to Elijah’s history, Dr. Mattson asserted that he “had no event
of inflammatory demyelination prior to the vaccine in question.” Dr. Mattson
disregarded Elijah’s reports of having difficulties with his left hand because Elijah
attributed them to a sports injury. In addition, Dr. Mattson appeared not to value
reports of double vision because Dr. Mattson had not obtained a similar history
from Elijah. Finally, Dr. Mattson asserted that even if Elijah had an episode of
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inflammatory demyelination, a vaccine provoked “the second and MS-defining
event.” Id. at 2.
The submission of this report and its accompanying literature prompted the
Secretary to retain an expert. On March 29, 2013, the Secretary filed a five-page
report from Dr. Sriram. Dr. Sriram agreed that Elijah suffers from multiple
sclerosis. In his view, Elijah actually was suffering from a previously undiagnosed
case of multiple sclerosis before he was vaccinated. In support, Dr. Sriram pointed
to the oligoclonal bands detected in Elijah’s cerebrospinal fluid 48 hours after
vaccination. Dr. Sriram maintained that the immune system could not generate
oligoclonal bands in such a short amount of time as the production of the relevant
antibody would take at least five days. As further evidence regarding the onset of
Elijah’s multiple sclerosis, Dr. Sriram identified left-hand weakness and double
vision as neurological symptoms. Dr. Sriram asserted that the vaccines Elijah
received do not cause a worsening in multiple sclerosis. Lastly, Dr. Sriram
disagreed with how Dr. Mattson explained the connection between ADEM and
multiple sclerosis. Exhibit A.
Ms. Hunt filed a response from Dr. Mattson on June 13, 2013. Dr. Mattson
maintained that “ADEM is part of the spectrum of inflammatory demyelinating
disease.” ADEM can be “the first event of what becomes a recurring pattern of
inflammatory demyelinating events to make a diagnosis of multiple sclerosis.”
Exhibit 38 at 1. Dr. Mattson generally indicated that vaccinations can cause
ADEM or can exacerbate multiple sclerosis, although Dr. Mattson did not identify
the process through which vaccinations can cause or aggravate a demyelinating
disease. See id. at 1-2.
Dr. Mattson presented a two-part construct for Elijah’s medical history
similar to what he presented in his previous report. Initially, Dr. Mattson
maintained that Elijah’s “multifocal demyelination began within a day of the
vaccinations,” starting when Elijah had a “febrile response.” Dr. Mattson stated
that he “dismissed the prior history of left hand difficulties and vague visual
complaints, as not significant enough for the patient to have sought medical
attention, and attributable in the case of the left hand symptoms to a sports related
injury.” Id.
Alternatively, if Elijah had experienced symptoms of multiple sclerosis
before vaccination as Dr. Sriram had asserted, then the events of April 22, 2011
constituted a “second and MS-defining event.” Dr. Mattson opined that the initial
pre-vaccination symptoms “may never have led to a recurrent pattern of
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inflammatory demyelination to make an MS diagnosis if he had not received the
vaccinations in question.” Id. at 2.
In the ensuing status conference, Ms. Hunt acknowledged that Dr. Mattson
had overlooked the question of timing. Dr. Mattson had not explained how the
vaccinations could cause multiple sclerosis when the cerebral spinal fluid taken
from Elijah 48 hours after vaccination contained oligoclonal bands. Hence, Ms.
Hunt was ordered to obtain another report from him. In addition, the parties were
encouraged to explore settlement. Order, issued July 3, 2013.
In response, Dr. Mattson revised his opinion, at least slightly. Dr. Mattson
agreed that the oligoclonal IgG bands were likely present in Elijah before
vaccination. The oligoclonal bands are “indicator[s] of ongoing immune
dysregulation or hyperactivity in the central nervous system.” Referencing a study
on twins with multiple sclerosis, Dr. Mattson asserted that a person could have
oligoclonal IgG bands but never have experienced “a clinical event suggestive of
inflammatory demyelination.” Exhibit 41 at 1 (citing exhibit 42 (Adrian Williams
et al., Multiple sclerosis in twins, 30 Neurology 1139 (1980))) at 1143. Dr.
Mattson opined that Elijah could have followed such a course. “Had these
vaccines not been given, this hyperactivity and predisposition might never have
been manifest as the fulminant and devastating ADEM event.” Exhibit 41 at 1.
In a discussion about Dr. Mattson’s opinion, Ms. Hunt stated that she was
pursuing a theory that the vaccinations aggravated an asymptomatic condition.
The parties also continued their preparation for a hearing and the Secretary was
ordered to obtain another report from Dr. Sriram.
Dr. Sriram’s September 3, 2013 report addressed the recent statements from
Dr. Mattson. With respect to the significant aggravation theory, which Dr.
Mattson had characterized as fueling the fires of inflammation, Dr. Sriram stated
that there is “no prospective study which has shown an increase in relapses after
vaccinations of any kind.” Exhibit H at 2. Dr. Sriram also questioned the
usefulness of the twin study because those authors stated that the “unaffected twins
with oligoclonal bands have subclinical MS.” Id. at 3.
After the Secretary filed this report, the undersigned issued an order for the
parties to file relatively lengthy briefs before the hearing. This order encouraged
Ms. Hunt to confirm with Dr. Mattson that he was opining that the vaccinations
significantly aggravated an underlying condition, as opposed to causing the
condition. If Ms. Hunt were pursuing a significant aggravation theory, the parties
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should present reports from their experts explaining how Elijah would have been
but for the vaccination. Order, issued Sep. 24, 2013 at 8-9 (citing Locane v. Sec'y
of Health & Human Servs., 685 F.3d 1375, 1381 (Fed. Cir. 2013); Loving v. Sec’y
of Health & Human Servs., No. 02-469V, 2009 WL 3094883, at *11-23 (Fed. Cl.
Spec. Mstr. July 30, 2009), recons. granted in part on other grounds, 2010 WL
1076124 (Fed. Cl. Spec. Mstr. Mar. 2, 2010); Gruber v. Sec'y of Health & Human
Servs., 61 Fed. Cl. 674, 684 (2004)).
On November 25, 2013, Ms. Hunt filed updated medical records and her
pretrial brief. Her pretrial brief asserted that she was entitled to compensation
through three different avenues: (1) Elijah suffered an encephalopathy as defined
in the Vaccine Injury Table, (2) the vaccinations caused Elijah to develop
“postvaccinal encephalomyelitis, which went on to be multiple sclerosis,” and (3)
the vaccinations significantly aggravated his multiple sclerosis. With respect to the
significant aggravation theory, Ms. Hunt did not file another report from Dr.
Mattson in which he discussed the expected course of multiple sclerosis. She
represented that “if Dr. Mattson were asked whether Elijah would never have
developed MS if it were not for the vaccinations, that Dr. Mattson would respond
that it is possible that Elijah would have lived his entire life without any
development that would trigger MS. But, Dr. Mattson cannot say for sure.”
Pet’r’s Prehr’g Br. at 41.
Dr. Sriram discussed Elijah’s anticipated course of multiple sclerosis in a
report filed on November 26, 2013. Dr. Sriram stated that the future course of
multiple sclerosis cannot be predicted easily. He also said that “[i]t is very
unlikely that vaccination alters the natural history of MS.” Exhibit N at 4. The
Secretary incorporated Dr. Sriram’s opinion into her pretrial brief, filed on
December, 16, 2013. The Secretary addressed each of the three theories of
recovery, explaining Ms. Hunt’s position was not persuasive.
After reviewing the parties’ pretrial submissions, the undersigned suggested
that they may wish to consider settlement before the forthcoming hearing. Order,
issued Dec. 18, 2013. The parties agreed to pursue this possibility. Settlement was
again discussed during the January 3, 2014 pretrial conference.
The parties’ efforts to resolve the case informally did not succeed. Thus, a
hearing was held on January 9, 2014. As permitted by Vaccine Rule 8(b)(2), Dr.
Mattson appeared via videoconferencing. Dr. Mattson was joined at the Indiana
videoconferencing facility by an associate attorney, Ms. Hunt, and Elijah. Ms.
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Hunt’s attorney of record was at the Office of Special Masters in Washington, DC,
where Dr. Sriram was.
Following the hearing, the parties submitted briefs. Ms. Hunt filed an initial
brief on March 10, 2014, and a reply brief on June 16, 2014.8 In between those
submissions, the Secretary filed one brief on May 23, 2014. Subsequently, the
undersigned again requested that the parties explore settlement. However, the
parties could not reach an agreement and submitted the case for adjudication.
As the expert reports and briefs have foreshadowed, two topics require
resolution. The first issue concerns Elijah’s health just before he was vaccinated.
While the experts agree that his immune system was dysregulated, Dr. Mattson and
Dr. Sriram draw different implications from the oligoclonal bands. The second
issue is whether vaccinations made Elijah’s health worse than it would have been
but for the vaccinations.
III. Standards for Adjudication
Petitioners are required to establish their cases by a preponderance of the
evidence. 42 U.S.C. § 300aa–13(1)(a). The preponderance of the evidence
standard requires a “trier of fact to believe that the existence of a fact is more
probable than its nonexistence before [he] may find in favor of the party who has
the burden to persuade the judge of the fact’s existence.” Moberly v. Sec’y of
Health & Human Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (citations
omitted). Proof of medical certainty is not required. Bunting v. Sec’y of Health &
Human Servs., 931 F.2d 867, 873 (Fed. Cir. 1991).
Distinguishing between “preponderant evidence” and “medical certainty” is
important because a special master should not impose an evidentiary burden that is
too high. Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1379-80
(Fed. Cir. 2009) (reversing special master’s decision that petitioners were not
entitled to compensation); see also Lampe v. Sec’y of Health & Human Servs., 219
F.3d 1357 (2000); Hodges v. Sec’y of Health & Human Servs., 9 F.3d 958, 961
(Fed. Cir. 1993) (disagreeing with dissenting judge’s contention that the special
master confused preponderance of the evidence with medical certainty).
8 In her initial brief and reply brief, Ms. Hunt did not assert that Elijah suffered an
encephalopathy as defined in the regulations associated with the Vaccine Injury Table.
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IV. Elijah’s Pre-Vaccination Status
The first matter requiring resolution concerns Elijah’s health before he
received the vaccines on April 20, 2011. The determination on this point controls
whether Ms. Hunt may pursue either a claim that the vaccinations caused Elijah a
new injury or a claim that the vaccinations significantly aggravated a pre-existing
condition.
The Court of Federal Claims has discussed the difference between the two
theories of recovery in a case involving parents who maintained that vaccines
caused their child’s developmental delay. The Secretary argued that the vaccines
were not causative because the child had manifested symptoms of a neurologic
injury before the vaccinations. The Court explained that the answer to this
question was to look for evidence of the disease for which the petitioners were
claiming compensation before the vaccination. “If [the child’s] neurological . . .
symptoms, however defined, were manifested pre-vaccination, then [his] case
involves a significant-aggravation claim. . . . If not, then [his] case concerns a new-
injury claim.” Paluck v. Sec'y of Health & Human Servs., 104 Fed. Cl. 457, 469
(2012) (remanding case), reversing decision after remand, 113 Fed. Cl. 210, 225
(2013), appeal filed, No. 14-5080 (Fed. Cir. Apr. 25, 2014). Accordingly, the
question in this case is whether Elijah manifested symptoms of multiple sclerosis
before the vaccination.9
9 In their post-hearing briefs, both parties discussed whether Elijah’s pre-vaccination
health affects the legal framework. Ms. Hunt argued that “[t]his is not a case where the [special
master] must diagnose the injury as a prerequisite to applying the Althen factors.” Pet’r’s Br.,
filed Mar. 10, 2014, at 18; accord Pet’r’s Reply, filed June 16, 2014, at 1-4. Ms. Hunt’s
argument is mistaken because the parties do not controvert Elijah’s diagnosis, unlike cases in
which the diagnosis was disputed and, therefore, became a prerequisite to the Althen analysis.
E.g., Lombardi v. Sec'y of Health & Human Servs., 656 F.3d 1343 (Fed. Cir. 2011);
Broekelschen v. Sec'y of Health & Human Servs., 618 F.3d 1339 (Fed. Cir. 2010). As discussed
in the text below, Ms. Hunt’s emphasis on whether the doctors caring for Elijah on April 22,
2011, could have diagnosed him as suffering from multiple sclerosis is misdirected.
The Secretary maintained that it was not necessary “to determine whether Elijah initially
suffered from ADEM, which developed into multiple sclerosis, or whether Elijah’s symptoms
were always attributable to his multiple sclerosis.” Resp’t’s Br., filed May 23, 2014, at 9.
Although the Secretary provided several reasons for this assertion, they boil down to the same
point --- Ms. Hunt cannot prevail on either the theory that Elijah suffered a new injury or the
theory that Elijah’s condition was significantly aggravated.
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On this narrow question, the parties have relatively little disagreement.
They mostly agree about the symptoms of multiple sclerosis and they mostly agree
about the symptoms that Elijah experienced.
Multiple sclerosis is a disease in which parts of a person’s immune system
are presumed to attack the person’s central nervous system. The specific
component of the central nervous system is myelin, which insulates the axons that
conduct electrical impulses throughout the brain and spinal cord. Tr. 13-14, 174.
Because myelin is attacked, multiple sclerosis is classified as a demyelinating
disease.10
Symptoms of multiple sclerosis include blurred vision, facial numbness,
urinary problems, and mild cognitive impairment. Exhibit 40 (DH Miller et
al., Differential diagnosis of suspected multiple sclerosis: a consensus approach,
14(9) Mul. Scler. 27 (2008)) at 27-28 (table 3); see also exhibit D (John H.
Noseworthy et al., Multiple Sclerosis, 343(13) The New England Journal of
Medicine 938 (2000)) at 938 (presenting an extensive list of signs and symptoms).
Some of these symptoms are similar to the symptoms of other demyelinating
diseases. Multiple sclerosis differs from diseases like ADEM because those other
demyelinating diseases tend be considered monophasic.11 Traditionally, to be
diagnosed with multiple sclerosis, a person must have “at least two events”
“disseminated in time and space.” Tr. 34; accord Tr. 71; exhibit 32 (Chris H.
Pulman et al., Diagnostic criteria for multiple sclerosis: 2010 revisions to the
McDonald criteria, 69 Ann. Neurol. 292 (2011)) at 295; exhibit 34 (Anita L.
Bellman et al., Challenges in the classification of pediatric multiple sclerosis and
future directions, 68 (Supp. 2) Neurology 1 (2012)) at 4; exhibit 40 (Miller) at 2.
Due to this overlap, Dr. Mattson and Dr. Sriram agreed that a person can have an
initial demyelinating episode that doctors may characterize as ADEM. When the
person has a second demyelinating episode, the doctors will then diagnose the
10 Other central nervous system demyelinating diseases include transverse myelitis, optic
neuritis, and ADEM. Dr. Mattson and Dr. Sriram disputed the taxonomic relationship between
multiple sclerosis and ADEM. Compare Tr. 84, 102 (Dr. Mattson), with Tr. 175-77, 207 (Dr.
Sriram).
11 To be more precise, Dr. Mattson asserted that ADEM can rarely have a multiphasic
course. Tr. 75. However, Dr. Sriram did not agree. Tr. 173. Because the experts agree that
Elijah’s current diagnosis is multiple sclerosis, there is no need to explore multiphasic ADEM in
more detail.
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person as suffering from multiple sclerosis. Tr. 21, 56, 110, and 135 (Dr.
Mattson), 175-76, and 228-29 (Dr. Sriram).12
Dr. Mattson’s and Dr. Sriram’s agreement about the features of multiple
sclerosis largely, but not entirely, carried over to an evaluation of Elijah’s health
before vaccination. A very important point of agreement concerns the presence of
oligoclonal bands in Elijah’s cerebrospinal fluid obtained on April 23, 2011.
Exhibit 5 at 339.
Before the hearing, Dr. Sriram interpreted Elijah’s oligoclonal bands as
inconsistent with a theory that the April 20, 2011 vaccinations caused an immune-
mediated reaction in Elijah’s central nervous system because the biologic process
that creates oligoclonal bands takes several days. Exhibit A at 3. Dr. Mattson was
instructed to respond to this specific aspect of Dr. Sriram’s report. Orders, issued
April 16, 2013 and July 3, 2013. In response, Dr. Mattson indicated that he agreed
that Elijah most likely had oligoclonal bands before the vaccination. Exhibit 41.
Dr. Mattson repeated this opinion at the hearing. Tr. 83-84, 91, 107. The presence
of oligoclonal bands signifies, at least, hyperactivity in the immune system. Tr.
251.
In addition to this sign of a dysregulated immune system, Elijah experienced
at least two symptoms that could be manifestations of a problem in his central
nervous system before vaccination. First, Elijah developed weakness in his
dominant hand, which happened to be his left hand. Exhibit 5 at 11. Second,
Elijah experienced episodes of double vision. Id. Dr. Sriram asserted that both a
switch in handedness and double vision were manifestations of a “neurological
abnormality” and were Elijah’s “first events.” Tr. 179-80. Dr. Mattson disagreed
because the left-handed weakness could have been the effect of a sports injury and
there was no medical confirmation of the double vision. Tr. 105-07; but see Tr.
148, 245.
The evidence favors a finding that Elijah experienced clinical symptoms of
multiple sclerosis before the April 20, 2011 vaccinations. Elijah testified that
numbness in his arm was the same as the numbness he felt on the left side of his
face one day after vaccination. Tr. 261. In addition, the reason Dr. Mattson gave
12 During the October 8, 2014 status conference, the undersigned discussed his review of
the transcript and recommended that respondent review the accuracy of Dr. Sriram’s testimony
on page 229 line 16. Order, issued October 9, 2014. Respondent clarified her expert’s
testimony. Resp’t’s Status Rep., filed Nov. 7, 2014.
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for discounting the report of double vision, the lack of objective verification, is not
persuasive. At age 12, Elijah is capable of reporting episodes of double vision
accurately. Neither Ms. Hunt nor Dr. Mattson has suggested that Elijah’s report
was erroneous. They simply argue it was unverified. However, verification is not
needed for double vision. Finally, the two symptoms tend to corroborate each
other.
Even if these clinical symptoms could be discounted, Dr. Mattson conceded,
on cross-examination, that before the vaccinations, Elijah suffered from subclinical
multiple sclerosis. Tr. 119. This finding carries medical and legal implications.
The legal consequence of finding that Elijah suffered clinical symptoms of
multiple sclerosis and had (undetected) laboratory evidence of multiple sclerosis
means that Ms. Hunt may pursue her significant aggravation theory only. Her
alternative theory of recovery, the new injury claim, is not tenable. Locane, 685 at
1381 (“Given the Special Master’s finding that the illness was present before the
vaccine was administered, logically, the vaccine could not have caused the
illness.”). A complete analysis of the significant aggravation claim is set forth in
section V below. As discussed in that section, a critical aspect of that analysis is
how Elijah would have progressed but for the vaccinations.
Predicting Elijah’s course as of April 19, 2011 (the day before the
vaccination) is nearly impossible. By April 19, 2011, Elijah had experienced such
problems in his dominant hand that he stopped writing with it for a time, had
episodes of double vision, and had abnormal antibodies in his cerebrospinal fluid.
A fundamental question is given this constellation of signs and symptoms, would
Elijah have experienced more overt episodes associated with demyelination?
For this question, the evidence was sparse and evidence based on more than
just opinion was rarer still. A series of examinations reflect refinement in Dr.
Mattson’s opinion. Initially, Dr. Mattson was asked whether, assuming that Elijah
had multiple sclerosis before the vaccinations, could he have “lived a normal life
without any further symptoms or complications?” Dr. Mattson responded:
“[T]hat’s a very likely possibility.” Tr. 92-93. On cross-examination, Dr. Mattson
was asked: “[W]hat is it about Elijah, in particular, that makes you believe that it’s
more likely than not that he never would have had a problem?” His response was:
“Perhaps the fact that he was young and it’s an unusual condition at a younger
age.” Tr. 117. Because Dr. Mattson’s first response was expressed as a “very
likely possibility,” Dr. Mattson was asked whether there is “a reasonable
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probability that Elijah would have had a normal life but for the vaccines?” His
answer was solely “Yes.” Tr. 161.
Dr. Sriram’s opinion was that before vaccination, Elijah had displayed
symptoms of multiple sclerosis (hand problems and double vision) and Elijah’s
deterioration after vaccination constituted a normal course of multiple sclerosis,
one that the vaccinations did not affect. See Tr. 196. For the predicted course of
multiple sclerosis, Dr. Sriram emphasized that in addition to the oligoclonal bands,
Elijah had abnormal vision and abnormal function in his arm. Those clinical
features change the expected “long-term course.” Tr. 232.13
The predictions about how Elijah would have fared as of April 19, 2011
(before the vaccinations and before he had his MRI) need to be placed in context
with predictions that could be made about Elijah as of his condition on April 29,
2011 (when he was discharged). Between April 21, 2011 and April 22, 2011,
Elijah felt dizzy and off-balanced, had swelling in his face, and, later, acted like he
had a stroke. After a CT and an MRI revealed lesions in his brain, doctors
diagnosed him as suffering ADEM. Exhibit 5 at 4 (discharge summary).
Based on an article, Dr. Mattson opined, that in zero to 28 percent of ADEM
cases, the individual is later diagnosed with multiple sclerosis. Tr. 35-36 and 74
(citing exhibit 35 (Silvia Tenembaum et al., Acute disseminated encephalomyelitis,
68 Neurology S23 (2007)) at S31). Tenembaum, in turn, relies upon four studies
in which the rates of multiple sclerosis were reported as 0%, 9.5%, 27%, and 28%.
The last study, whose lead author is Yann Mikaeloff and which is reference 39 in
the Tenembaum article, appears in the record as exhibit Q (Yann Mikaeloff et
13 The simple presence of oligoclonal bands does not necessarily augur the development
of multiple sclerosis. The Williams study on twins suggests that some people can have
oligoclonal bands but not any clinical symptoms. Exhibit 42 (Williams) at 1146. Dr. Sriram
agreed with this conclusion. Tr. 230. When Dr. Mattson was asked about the significance of the
oligoclonal bands, he stated Elijah “could have had those bands forever and never caused a
problem. We don’t know.” Tr. 116.
Scientists have relatively little information about whether oligoclonal bands can be useful
in predicting the course of multiple sclerosis. One problem is that because spinal taps are
invasive procedures, doctors do not perform them without a good reason.
This lack of knowledge contributed to an erroneous argument the Secretary offered. The
Secretary pointed out that approximately 90 to 95 percent of people with multiple sclerosis have
oligoclonal bands. Resp’t’s Br. filed May 23, 2014 at 27. However, this statistic is not quite on
point. The better but unknown piece of information is the percentage of people with positive
oligoclonal bands who develop multiple sclerosis.
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al., First Episode of Acute CNS Inflammatory Demyelination in Childhood:
Prognostic Factors for Multiple Sclerosis and Disability, 144 J Peds 246 (2004)) at
249. Ms. Hunt emphasizes that even if the highest figure is accepted (28 percent),
then in more than two-thirds of ADEM cases, the person is not later diagnosed
with multiple sclerosis. Pet’r’s Br. at 18; Pet’r’s Reply at 3, 8, 10.
Dr. Sriram’s opinion on this point was not presented well. Although Dr.
Mattson had disclosed the zero to 28% range in his reports, Dr. Sriram did not
respond to this aspect in his pre-trial disclosures. When the undersigned asked for
Dr. Sriram’s opinion during the hearing, he stated that 60 percent of people with
ADEM go on to suffer a second demyelinating event (thereby satisfying the
diagnostic criteria for multiple sclerosis) within five years. The problem was that
Dr. Sriram did not cite articles for the basis of his opinion. Tr. 185. In the
Secretary’s brief, she attempted to fill this gap by citing to the Mikaeloff article.
Resp’t’s Br. at 40 n.17.
Unfortunately, neither expert testified about the Mikaeloff article, making an
interpretation of it difficult.14 When experts do not discuss an article, special
masters are not required to decipher its meaning after a party cites it in a post-
hearing brief. Moberly v. Sec’y of Health & Human Servs., 85 Fed. Cl. 571, 598
(2009), aff’d, 592 F.3d 1315 (Fed. Cir. 2010).
In any event, even if Dr. Sriram’s estimate that 60 percent of children who
experience a demyelinating attack have a second event within five years were
credited, there would remain a substantial minority of children who do not have a
second attack. Ms. Hunt’s theory is that absent the vaccination, Elijah would have
belonged in the group of children who experienced only a single event. Dr.
Mattson averred: If what happened in April were a second event, “then it was
triggered in particular by the vaccine and that’s led to the fact that he has gone on
to have a pattern of reoccurrence. He may never have had another event because,
again, people with their first clinical event may never go on to have another event.”
Tr. 83.
Given the finding that Elijah was suffering from multiple sclerosis before the
vaccination, Ms. Hunt may recover compensation by establishing that the
14 Similarly another article, which the experts did not discuss, estimated that the chance a
person who had a clinically isolated syndrome with an abnormal MRI will develop multiple
sclerosis in two years at 50 percent. Exhibit C (Alastair Compston et al., Multiple sclerosis, 372
Lancet 1503 (2009)) at 1503.
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vaccinations significantly aggravated Elijah’s multiple sclerosis. The following
section analyzes this cause of action.
V. Significant Aggravation
As confirmed in W.C. v. Sec'y of Health & Human Servs., 704 F.3d 1352,
1357 (Fed. Cir. 2013), the elements of an off-Table significant aggravation case
were stated in Loving. There, the Court blended the test from Althen v. Sec'y of
Health & Human Servs., 418 F.3d 1274, 1279 (Fed. Cir. 2005), which defines off-
Table causation cases, with a test from Whitecotton v. Sec'y of Health & Human
Servs., 81 F.3d 1099, 1107 (Fed. Cir. 1996), which concerns on-Table significant
aggravation cases. The resulting test has six components. These are:
(1) the person's condition prior to administration of the
vaccine, (2) the person's current condition (or the
condition following the vaccination if that is also
pertinent), (3) whether the person's current condition
constitutes a “significant aggravation” of the person's
condition prior to vaccination, (4) a medical theory
causally connecting such a significantly worsened
condition to the vaccination, (5) a logical sequence of
cause and effect showing that the vaccination was the
reason for the significant aggravation, and (6) a showing
of a proximate temporal relationship between the
vaccination and the significant aggravation.
Loving, 86 Fed. Cl. at 144. Each element is discussed below.
A. Theory
One way to analyze the six Loving prongs is to start with the fourth prong,
which corresponds to the first prong of Althen. Hennessey v. Sec'y of Health &
Human Servs., No. 01-190V, 2009 WL 1709053, at *42 (Fed. Cl. Spec. Mstr.
May 29, 2009), mot. for rev. denied, 41 Fed. Cl. 126 (2010). This approach brings
to the forefront the question of whether the vaccine can cause a significant
aggravation.
Through Dr. Mattson, Ms. Hunt advances two theories (molecular mimicry
and bystander activation). Dr. Mattson opined that these theories explain how
vaccines can cause ADEM and whatever can cause ADEM can also cause multiple
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sclerosis. Pet’r’s Br. at 25-30. When Dr. Mattson was pressed to explain which of
the three vaccines Elijah received harmed him, he focused on the varicella vaccine.
Unlike the Tdap and pneumococcal vaccines, the varicella vaccine contains a live
attenuated virus. Tr. 119.
Identifying the particular vaccine relevant to a claimed injury is an aspect of
petitioner’s obligation to “provide a reputable medical or scientific explanation that
pertains specifically to the petitioner’s case.” Broekelschen, 618 F.3d at 1345.
Information about the possible harmful side effects of other vaccines may
constitute “existing data” from which an expert may extrapolate. See Gen. Elec.
Co. v. Joiner, 522 U.S. 136, 146 (1997). Whether this extrapolation is reasonable
depends upon many factors, including the extent to which the expert has explained
why the vaccines are analogous. See Cedillo v. Sec'y of Health & Human Servs.,
617 F.3d 1328, 1339 (Fed. Cir. 2010). Here, a predicate for Dr. Mattson’s theory
is that some vaccines may cause ADEM. The specific vaccines are the rabies
vaccine and the smallpox vaccine. Dr. Sriram seemed to accept the proposition
that older form of the rabies vaccine can cause ADEM. See exhibit A (Dr.
Sriram’s report) at 4; Tr. 171. The accepted basis for the causal connection is that
the rabies vaccine contained remnants of neural tissue. Exhibit 34 (Hans-Peter
Hartung et al., ADEM: Distinct disease or part of the MS spectrum?, 56 Neurology
1257 (2012)) at 1257; Tr. 78.
While Dr. Mattson cited articles linking either rabies vaccine or smallpox
vaccine to ADEM, none of these articles linked those vaccines to multiple
sclerosis, as Dr. Mattson conceded on cross-examination. Tr. 103. Further, one
study looked for articles linking rabies vaccine and multiple sclerosis. These
authors found two articles and concluded that both showed “a null association.”
Exhibit G (Mauricio F. Farez et al., Immunization and risks of multiple sclerosis:
systematic review and meta-analysis, 258 J. Neurology 1202 (2011)) at 1202.
Besides the rabies vaccine and the smallpox vaccine, there appears to be less
acceptance that vaccines can cause encephalomyelitis. Tr. 157-58.
As to whether any of the vaccines that Elijah received (the Tdap, varicella,
and meningococcal vaccines) can cause multiple sclerosis, the Secretary presented
two valuable studies: the articles by Farez and Confavreux. Exhibit E (Christian
Confavreux et al., Vaccinations and the risk of relapse in multiple sclerosis, 344(5)
The New England Journal of Medicine 319 (2001)) at 324 (table 3). These studies
support the proposition that the varicella vaccine (Farez) and the Tdap vaccine
(Confavreux and Farez) do not affect multiple sclerosis.
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The Confavreux researchers studied 643 people with multiple sclerosis who
received various vaccines, including the tetanus vaccine. The authors examined
whether the participants suffered more relapses of their multiple sclerosis during
the two months after vaccination compared with relapses at other times. For
combined tetanus vaccines, the relative risk was 0.22 and the 95 percent
confidence interval was 0.05-0.99.15 The authors concluded: “Most vaccinations,
especially those against tetanus plus poliomyelitis or diphtheria, were actually
associated with a lower risk of relapse, although the difference was not
significant.” Id. Dr. Mattson recognized that a relative risk of 0.22 suggests that
receipt of the tetanus vaccine actually protected the individual against relapses. Tr.
122. Because the people in the Confavreux study already had multiple sclerosis
when they were vaccinated, Elijah closely resembles those participants and the
findings from the study provide some information about his case.
The other significant study was by Farez and colleagues. This group looked
through various databases to find results of randomized clinical trials and non-
randomized studies that examined whether various vaccinations affect the
likelihood of developing multiple sclerosis or having a relapse. Exhibit G (Farez)
at 1198. The located studies were the basis for a meta-analysis in which the
researchers pooled data from the individual studies. Id.; Tr. 122-23, 189.
Pertinent to Elijah’s case, Farez and colleagues analyzed vaccines against
tetanus, varicella, diphtheria, diphtheria-tetanus-pertussis, and pertussis.16 Except
for the varicella vaccine, Farez et al. concluded that the vaccines were not
associated with a higher risk of developing multiple sclerosis or higher risk of
relapse. Exhibit G (Farez) at 1203.
For the varicella vaccine, the Farez researchers identified only one study,
which was the Zorzon study. Exhibit G (Farez) at 1201. The Farez group declined
to draw a causal connection and cited three studies, including the Confavreux
study, as “fail[ing] to establish a link between vaccinations and MS.” Id.
Furthermore, Ms. Hunt did not elicit any testimony regarding Zorzon and did not
15 The information for the combined tetanus vaccine differed from the information for the
tetanus vaccine alone. For just the tetanus vaccine, the relative risk was 0.75 with a 95%
confidence interval of 0.23-2.46.
16 The researchers could not find any studies regarding the meningococcal vaccine.
Exhibit G (Farez) at 1204.
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cite this study in either her posthearing brief or posthearing reply. Consequently,
no weight is given to the Zorzon study.
Without Zorzon, the epidemiological evidence is inconsistent with a theory
that a vaccination can cause or worsen multiple sclerosis. Ms. Hunt’s response is
to challenge the value of epidemiological evidence because of the small sample
sizes. Pet’r’s Br. at 29. In Dr. Mattson’s view, vaccines can cause neurologic
events so rarely (perhaps at a rate of one case of ADEM per 3 million doses of
vaccine) that any epidemiological study would need to involve millions of
people.17 Thus, because the Confavreux study involved fewer than 700 people, the
results are not meaningful. Tr. 109-10.
The soundness of Dr. Mattson’s criticism is difficult to assess because Dr.
Mattson does not have any training in epidemiology. Tr. 131. Likewise, although
Dr. Sriram had confidence in the statisticians in Confavreux’s group, Dr. Sriram
does not have any specialized knowledge about statistics. Tr. 188. For their part,
Confavreux and colleagues asserted that their study design was strong because data
exposures were collected during the entire period, patients were unaware of
hypothesis, and medical records confirmed patient’s documentation. They
represented that it had a “90 percent power to detect a doubling of the risk of
relapse within two months of vaccination.” Exhibit E at 325.
The ability of epidemiologic studies to detect an increased incidence of rare
events is a recurring question. See Knudsen v. Secʼy of Health & Human Servs.,
35 F.3d 543, 550 (Fed. Cir. 1994) (discussing relative infrequency of
encephalopathies caused by the diphtheria-tetanus-pertussis vaccine). In the
Vaccine Program, petitioners may establish that a vaccine can cause a disease
without submitting an epidemiologic study. Capizzano v. Sec'y of Health &
Human Servs., 440 F.3d 1317, 1325 (Fed. Cir. 2006). But, the Federal Circuit has
17 Dr. Mattson’s estimate comes from an analysis of a European database that collects
reports of adverse events following varicella vaccination. The researchers reported that after 3.3
million doses of varicella vaccine had been distributed over five years, there was one report of
ADEM. Exhibit I (Nicolas Golleret et al., Safety profile of live varicella virus vaccine
(Oka/Merck): Five-year results of the European Zoster Virus Identification Program (EU
VZVIP), 28 Vaccine 5878 (2010)) at 5879-80. However, this report of ADEM after vaccination
does not establish that the vaccination caused the ADEM. See Analla v. Sec’y of Health &
Human Servs., 70 Fed. Cl. 552, 558 (2006) (noting that the VAERS database may not provide
reliable evidence regarding causation).
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also ruled that in denying compensation, a special master may rely on
epidemiologic studies that cast doubt upon the causal theory asserted. W.C., 704
F.3d at 1361 (citing Confavreux); Grant v. Sec'y of Health & Human Servs., 956
F.2d 1144, 1149 (Fed. Cir. 1992)(“epidemiological studies are probative evidence
relevant to causation”).18
In accord with these precedents, Farez and Confavreux constitute some
evidence that contradicts or at least undermines the theory that vaccinations cause
or worsen multiple sclerosis. See Bazan v. Sec’y of Health & Human Servs., 539
F.3d 1347, 1353 (Fed. Cir. 2008) (holding that special masters may consider
evidence that the government has introduced in determining whether a petitioner
has met her burden of proof). But, these epidemiologic studies cannot establish
that it is impossible for vaccines to affect multiple sclerosis. Thus, it is necessary
to examine the specific theories Dr. Mattson advanced to explain how a
vaccination can cause or worsen multiple sclerosis.
To link vaccinations and multiple sclerosis, Dr. Mattson presented two
theories. First, Dr. Mattson proposed molecular mimicry. Second, Dr. Mattson
offered bystander activation. See Pet’r’s Posthr’g Br. at 26.
Molecular mimicry is based upon an assertion that the molecular structure of
vaccines resembles (or mimics) the molecular structure of tissue found in the body.
Tr. 52 and 60 (Dr. Mattson), 181 (Dr. Sriram agreed with Dr. Mattson’s
description of molecular mimicry). Researchers have proposed molecular mimicry
as a method to explain how infectious agents may cause ADEM, although this
theory remains unproven from a scientific standpoint. See exhibit 35
(Tenembaum) at S32 (“microbial infections”); exhibit 37 (Alex Tselis and Robert
P. Lisak, Acute disseminated encephalomyelitis, Clinical Neuroimmunology 147
(2005)) at 153 (“infecting virus or other antigen”); exhibit 34 (Hartung) at 1259
(“[v]iral or bacterial superantigens”). From this foundation, Dr. Mattson
18 After briefing in Ms. Hunt’s case closed, the Federal Circuit issued an opinion critical
of the (undersigned) special master’s citation to epidemiological studies. Koehn v. Sec'y of
Health & Human Servs., 773 F.3d 1239, 1243 (Fed. Cir. 2014). However, Koehn did not
overrule W.C. and Grant, which remain binding precedent. South Corp. v. United States, 690
F.2d 1368, 1370 n.2 (Fed. Cir. 1982) (en banc); Johnston v. IVAC Corp., 885 F.2d 1574, 1579
(Fed. Cir. 1989). The continued vitality of the acceptance of epidemiology in W.C. is significant
because Ms. Hunt’s case and W.C. involved the same studies.
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extrapolates from infectious agents to vaccines and from ADEM to multiple
sclerosis. Tr. 69 (discussing exhibit 37 (Tselis)), 111.
The obstacle is that there is no basis for finding any similarity between any
of the vaccines at issue here and neurologic tissue. Tr. 119-20 (Dr. Mattson). Dr.
Sriram questioned the reliability of the molecular mimicry theory. He stated:
“The evidence that any of the human autoimmune diseases are based on molecular
similarities between an antigen or part of the protein in the central nervous system
. . . is still very hypothetical.” Tr. 181. Dr. Sriram explained that scientists have
looked for similarities between vaccines and myelin basic protein but not found
any similarities. Id. Thus, Dr. Sriram characterized molecular mimicry as “a
biological possibility.” Id.
Dr. Sriram’s description fits. Dr. Mattson has provided a theory of what
might happen, but he has not presented persuasive evidence that molecular
mimicry does happen with the relevant vaccines. Ms. Hunt seems to argue that
requiring more supporting evidence from Dr. Mattson would erroneously raise her
burden of proof. See Pet’r’s Posthr’g Br. at 30.19
Ms. Hunt is not correct. Judges at the Court of Federal Claims have
explained that special masters do not err when they require petitioners establish the
reliability of an expert’s opinion. See La Londe v. Sec'y of Health & Human
Servs., 110 Fed. Cl. 184, 201 (2013) (the petitioner's expert “could not back up his
hypothesis with a reliable medical or scientific explanation.... [The special master]
quite properly required petitioner to carry her burden to bring forward a reliable
medical or scientific explanation”), aff’d, 746 F.3d 1334, 1340 (Fed. Cir.
2014); Langland v. Sec'y of Health & Human Servs., 109 Fed. Cl. 421, 441 (2013)
(“the Special Master did not commit a legal error by requiring a sufficiently-
detailed explanation of how” a vaccine can cause a disease); Taylor v. Sec'y of
Health & Human Servs., 108 Fed. Cl. 807, 819 (2013) (“the mere existence” of
expert testimony about a theory “is insufficient to satisfy the burden of showing a
‘persuasive’ medical theory—this theory must also preponderate”). More
specifically, an evaluation to see whether a vaccine at issue is structurally similar
to relevant human tissue is consistent with the special master’s role in determining
whether a petitioner has established the first Althen prong. W.C., 704 F.3d at
19 Ms. Hunt also argues that Dr. Mattson’s opinion is entitled to deference because he
treated Elijah. Pet’r’s Posthr’g Br. at 25-26. This argument is discussed below in section C.
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1360; Caves v. Sec’y of Health & Human Servs., 100 Fed. Cl. 119, 135
(2011), aff’d without op., 463 Fed. Appx. 932 (Fed. Cir. 2012).
Ms. Hunt’s evidence regarding molecular mimicry is about the same as
evidence in these other cases. Molecular mimicry is plausible as a theory, in the
sense that molecular mimicry is consistent with how the immune system responds.
But, when the question turns from plausibility to legal probability, Ms. Hunt’s
claim falters. She has not established that it is likely that any of the vaccines Elijah
received can cause multiple sclerosis via molecular mimicry.
The second theory, bystander activation, actually has less evidentiary
support than molecular mimicry. Dr. Mattson briefly mentioned the bystander
activation theory in his testimony but did not explain it very well. See Tr. 59-60.
Dr. Mattson referred to the Tselis article as describing bystander activation, but his
testimony was only two sentences. Tr. 69. The article does not use the term
“bystander activation” so additional testimony by Dr. Mattson would have been
useful. Additionally, in the portion of the article that appears to be most relevant,
the authors present a “possible mechanism.” Exhibit 37 (Tselis) at 153. With the
relatively sparse evidentiary support of bystander activation, Ms. Hunt’s arguments
about bystander activation are conclusory. Pet’r’s Posthr’g Br. at 26-27; Pet’r’s
Reply at 5-6.
In sum, Ms. Hunt has not met her burden of proof to present a theory that
explains how a relevant vaccine can cause (or can significantly aggravate) multiple
sclerosis. This finding is based upon epidemiologic studies that have looked for a
connection between vaccinations and multiple sclerosis and have not found such.
This finding is also separately based upon the two theories Dr. Mattson posited,
molecular mimicry and bystander activation. Dr. Mattson did not present
persuasive evidence that either theory shows that it is more likely than not that the
vaccines contribute to multiple sclerosis.
B. Timing
Another aspect of Ms. Hunt’s case that she is required to establish is that the
significant aggravation arose in a time in which it is medically acceptable to infer
that a vaccine caused the worsening. The appropriate temporal relationship is
reflected in the third prong in Althen. 418 F.3d at 1278. After Althen, other
Federal Circuit cases have explored dimensions of the timing aspect and Loving, as
confirmed by W.C., imported the timing requirement from causation cases into
significant aggravation cases.
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The Federal Circuit interpreted Althen as permitting a special master to find
that an alleged reaction to a vaccine occurred too quickly after the vaccination to
support a causal relationship. Bazan, 539 F.3d at 1352. Thus, Bazan stands for the
legal proposition that a petitioner must establish the appropriate temporal
relationship between the vaccination and the onset of the problem for which the
petitioner seeks compensation. This temporal relationship must be neither too
soon nor too long. Bazan also demonstrates that the special master does not have
to accept the testimony of a treating doctor regarding the appropriate temporal
relationship.
The Court of Federal Claims recognized that the third prong of Althen
actually contains two parts: the medically acceptable interval and the date on
which the symptoms began. Shapiro v. Sec’y of Health & Human Servs., 101 Fed.
Cl. 532, 542-43 (2011), recons. denied after remand on other grounds, 105 Fed. Cl.
353 (2012), aff’d without op., 503 Fed. Appx. 952 (Fed. Cir. 2013). In accord with
the structure identified in Shapiro, these two aspects are addressed.
1. Medically Acceptable Interval
At hearing, Dr. Mattson offered the opinion that Elijah’s neurologic
symptoms began two days after vaccination and that two days is a medically
acceptable interval. On direct examination, his testimony on this topic was only a
few lines:
Q. Do you believe there is a proximal
temporal relationship between the vaccines and Elijah’s
injuries?
A. Yes.
Q. Tell the Court, if you would, please, why
you believe that.
A. Because it occurred within the three -- I
guess the focal signs develop within a couple days of the
vaccine -- two days of the vaccine and then, ultimately,
develop into a more full-blown stuttering bimodal onset
of different areas of inflammation in the brain.
Tr. 62; see also Tr. 92, 115-16. Later, Dr. Mattson identified the Scott article as
supporting an incubation period of 2 to 18 days. Tr. 64. Ms. Hunt relies upon Dr.
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Mattson’s testimony, the Scott article, and the Tenembaum article. Pet’r’s
Posthr’g Br. at 36.
When Dr. Scott wrote his article in 1967, the smallpox vaccination was still
administered. He reported that children under two years old developed
encephalitis after smallpox vaccination in “2 to 18 days.” Exhibit 36 (Thomas F.
McNair Scott, Postinfectious and Vaccinal Encephalitis, 51(3) Medical Clinics of
North America 701 (1967)) at 705 (table 3). However, the incubation period in
children older than two years old differed. In the older children, the interval was
“8 to 15 days.” Id.
On cross-examination, this difference was pointed out to Dr. Mattson. He
was asked why the latency period differed, and Dr. Mattson said he did not know.
Tr. 156-57. Because Elijah was 12 years old, the Scott article does not support Dr.
Mattson’s opinion that two days is an acceptable interval.
The remaining article is by Tenembaum and colleagues. They stated:
“Postinfectious forms of ADEM typically begin within 2 to 21 days after an
infectious event.” Exhibit 35 at S32. Unfortunately, neither Dr. Mattson nor Dr.
Sriram was asked about this particular passage.
Dr. Sriram testified more generally about the appropriate medical interval.
Dr. Sriram stated that the process by which a vaccination can trigger the immune
system to attack myelin in a person’s brain would usually take approximately one
week. Individual steps in this process include: presenting parts of the vaccine to
the regional lymph nodes, recognizing the vaccine as something foreign, producing
an appropriate T cell response, amplifying the T cell response through division,
crossing the blood brain barrier, (mis)identifying myelin in the brain as a foreign
substance, multiplying again, and then attacking the myelin. Tr. 236-37; see also
Tr. 192. Dr. Sriram stated that it is “highly unlikely for the kinetics of the time
frame of lymphocytes to react, activate, travel through the nervous system, recruit,
damage myelin and develop symptoms in a two-day time frame. It’s extremely
unlikely.” Tr. 193; accord exhibit A (Dr. Sriram’s report) at 3. In Dr. Sriram’s
view, the amount of time to develop neurologic deficits is “usually five to seven
days.” Tr. 193.20
20 As the Secretary noted, several articles are consistent with a latency period of
approximately one week. Resp’t’s Br. at 33. These articles include: exhibit 31 (Til Menge et
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On rebuttal, Dr. Mattson was given an opportunity to address Dr. Sriram’s
opinion that the kinetics of antibody production leading to neurologic problems
takes at least five days. Dr. Mattson did not challenge the sequence of steps and he
did not challenge that the expected amount of time is at least five days. See Tr.
242-43, 249-50. Instead, Dr. Mattson’s opinion was that Elijah’s pre-vaccination
health decreased the required amount of time. The oligoclonal bands in Elijah’s
cerebrospinal fluid indicated that his “immune system [was] already primed . . . to
take off with him more quickly.” Tr. 251.
Dr. Mattson’s idea that an individual who was primed to respond to an
antigen will respond to a repeated exposure of that antigen more quickly has some
merit. A foundation for vaccination is that immunized people will mount an
immune response to defend themselves against infectious organisms rapidly and
strongly. Although neither expert testified about some of the basic principles of
immunology, the undersigned has frequently heard testimony from experts retained
by both petitioners and respondents about how the immune system operates. This
background provides a basis for considering Dr. Mattson’s priming
theory. See Lampe, 219 F.3d at 1362 (noting that special masters may use their
“accumulated expertise” to resolve cases).
For the priming theory, Dr. Mattson has left unanswered at least two
questions. First, the priming theory seems based upon a similarity between the
initial antigen and the latter antigen. For example, the measles vaccine primes a
person to respond to the measles virus. However, as Dr. Mattson conceded on
cross-examination, the initial agent that prompted Elijah to develop oligoclonal
bands is not known. Tr. 115-16. Without this knowledge, Dr. Mattson must be
assuming that a relevant vaccine was somehow similar to the spark for Elijah’s
multiple sclerosis and there is no evidence to support this assumption.
Second, even if priming were assumed, Dr. Mattson has not attempted to
quantify how quickly a primed immune response would take. If a normal immune
al., Acute Disseminated Encephalomyelitis, 62 Arch Neurol 1673 (2005)) at 1674 (latency of 7
to 14 days); exhibit 29 (Richard T. Johnson et al., Postinfectious Encephalomyelitis, 5(2)
Seminars in Neurology 180 (1985)) at 183 (the latency between rabies vaccination and
encephalomyelitis was 10 to 41 days); exhibit 37 (Tselis) at 5 (the latency between infection and
ADEM is one to three weeks). The Secretary cited these articles as a basis to contradict the
latency reported in Tenembaum, which was 2 to 21 days. Unfortunately, again, neither Dr.
Mattson nor Dr. Sriram testified about the latency periods that Menge, Johnson, and Tselis
reported.
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process takes five days, how fast is a primed immune response? Dr. Mattson did
not say. Dr. Sriram stated that in animal models of experimental autoimmune
encephalitis, primed animals have been reported to respond in three days. Tr. 193.
Overall, the evidence is mixed and both sides could have presented their
positions more thoroughly. In support of Ms. Hunt’s assertion that two days is
appropriate, she fairly pointed to Dr. Mattson’s testimony, the Tenembaum article,
and the general theory that primed individuals respond more quickly. In contrast,
the Secretary pointed to the uncontradicted testimony from Dr. Sriram that a
normal immune-mediated response takes at least five days, the articles that
mentioned a five, seven, or ten day interval, and Dr. Sriram’s testimony that
primed animals take three days to respond.
This evidentiary record supports a finding that three days is an acceptable
temporal relationship in a case where the immune system is primed. Specific
reasons include that the majority of the articles indicated the temporal relationship
was at least five days. Although Ms. Hunt’s reliance upon Tenembaum’s
statement about “2 days” is legitimate, the Tenembaum article provided no basis
for the statement. Furthermore, Dr. Sriram has detailed the biologic processes that
must occur for a vaccination to lead to an immune-mediated neurologic problem.
Dr. Sriram’s research on experimental models gives him a foundation for opining
on how long immune processes underlying molecular mimicry, such as cell
division, take. See Tr. 192-93. Dr. Mattson was not willing to opine how much
time is needed for cells to divide. Tr. 250.
From the starting point of five days, the priming theory suggests a faster
response. Although Dr. Mattson’s explanation about this theory was not strong, it
is reasonable to accept that the oligoclonal bands suggest some aberration in
Elijah’s immune system could contribute to a quicker reaction. Ms. Hunt, as noted
above, did not provide any basis for finding that the reaction would be so fast that
it would happen in two days. Dr. Sriram’s testimony that even primed animals
take three days, although based upon articles that were not filed into the record,
fills this gap.
2. Onset of Elijah’s Acute Neurologic Problem
The second aspect of the temporal relationship prong from Althen concerns
when the vaccinee’s problems arose. This is another disputed point between the
parties. For the reasons explained below, the Secretary’s position that Elijah’s
neurologic problems started the day after vaccination is credited.
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Initially, it appeared that the parties were not disputing when Elijah’s
neurologic problems began. In Dr. Mattson’s first substantive report, he stated:
“Within a day of vaccination (Tdap, varicella, Meningococcal), associated with a
febrile inflammatory response, Elijah McLeod developed symptoms and signs of
multifocal inflammation in his white matter (dizziness, bilateral leg weakness, left
leg weaker, right eye visual decrease, left face numbness).” Exhibit 26 at 1.
Dr. Sriram did not contest this onset. In his first report, Dr. Sriram wrote:
Elijah’s “symptoms began within 24 hours after the receipt of the vaccinations.”
Exhibit A at 2. In this report, Dr. Sriram also asserted that the time for the immune
system to generate a response to the vaccine would be at least five days, and, thus,
the vaccinations could not have caused the bands of antibodies detected as
oligoclonal bands. Id. at 3-4.
Dr. Mattson’s next report started to blur different symptoms. Dr. Mattson
wrote: “The event in question of multifocal demyelination began within a day of
the vaccinations (Tdap, meningococcal conjugate, varicella) in question, with a
febrile response and the next day more focal neurological complaints.” Exhibit 38
at 1. Dr. Mattson did not identify the complaints that he considered to be “more
focal.”
More specificity came in Dr. Mattson’s final report. He stated: “Elijah
McLeod received the vaccinations in question on 4/20/2011, had dizziness and
vomiting starting 4/21/2011, developed focal neurologic symptoms and signs
starting on 4/22/2013.” Exhibit 41. The combination of these two reports suggests
that Dr. Mattson considered Elijah’s dizziness and vomiting, which he had on
April 21, 2011, to be a febrile response to the April 20, 2011 vaccination.
Dr. Mattson’s direct testimony about the temporal relationship was thin. He
simply said that Elijah’s “focal signs develop[ed] within a couple days of the
vaccine.” Tr. 62. He did not elaborate.
On cross-examination, Dr. Mattson was asked about his earlier reports in
which he wrote about Elijah developing problems “within a day of vaccination.”
Dr. Mattson conceded that his reports did say this, but he said he “was off a day.”
Tr. 113-14. Dr. Mattson maintained that his second report corrected the first report
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in that the second report said that a febrile response began within a day of
vaccination. Tr. 114; see also exhibit 38.21
Dr. Sriram’s testimony was consistent with his reports. Dr. Sriram opined
that on April 21, 2011, which is the day following vaccination, Elijah was
demonstrating neurologic symptoms. Dr. Sriram point out that Elijah was dizzy,
unsteady in his gait, and had fullness in the left side of his face. Tr. 193-94.
The evidence preponderates in favor of finding that Elijah was having
neurologic problems on April 21, 2011. In Dr. Mattson’s first report, he listed
“dizziness” and “left face numbness” as examples of “symptoms and signs of
multifocal inflammation in his white matter.” Exhibit 26 at 1. While Dr. Mattson
attempted to push the onset of neurologic problems ahead to April 22, 2011, on
April 21, 2011, Elijah did report he was feeling dizzy and his mother said his face
was full. Exhibit 4 at 3.
Ms. Hunt did not present any reason for discounting these problems as
manifestations of a neurologic problem. On cross-examination, Dr. Mattson
agreed that dizziness and unsteadiness are “nonspecific” neurologic symptoms. Tr.
115. Dr. Sriram explained that a weakness in facial muscles can cause a person to
appear to have a swollen face. Tr. 193-94. Dr. Mattson did not seriously challenge
Dr. Sriram’s explanation, saying it was “certainly a possibility.” Tr. 248.
Ms. Hunt’s brief emphasizes the symptoms that Elijah experienced on April
22, 2011. See Pet’r’s Br. at 36. But, this emphasis is misplaced in that the
Secretary does not dispute that the April 22, 2011 problems, like difficulty with
balance, were manifestations of a neurologic problem. The issue concerns the
symptoms on April 21, 2011, and, on this point, the evidence favors a finding of
neurologic problems.
3. Summary
The interval between the April 20, 2011 vaccinations and when Elijah
experienced symptoms of his neurologic disease has been a difficulty for Ms. Hunt
21 Ms. Hunt argues that the “febrile response was a localized reaction to the
vaccinations.” Pet’r’s Br. at 37. However, in the cited portion of the transcript (page 114), Dr.
Mattson does not describe Elijah’s fever as part of a localized reaction. Instead, in other places
in the transcript, Dr. Mattson equates Elijah’s sore arm as part of a localized reaction. Tr. 26,
249.
34

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throughout this litigation. Ultimately, the evidence suggests that an immune-
mediated reaction in a person with an intact central nervous system takes at least
five days. Because Elijah’s central nervous system already contained some
antibodies (as detected as oligoclonal bands), he might respond more rapidly.
Although Ms. Hunt’s proof for this proposition was not especially persuasive, a
generous estimate in her favor is that the interval might be as few as three days.
Shortening the interval from five days to three days still does not assist Ms.
Hunt. The evidence supports her conclusion that, more likely than not, Elijah
developed symptoms of a neurologic disorder within only one day. She has not
presented any evidence to show that the necessary steps can occur so quickly.
Consequently, Ms. Hunt has failed to meet her burden of proof regarding the
appropriate temporal interval.
C. Logical Sequence
For reasons just explained, Ms. Hunt has failed to present a persuasive
theory explaining how a vaccine can worsen multiple sclerosis and she has not
established that any worsening could occur within one day. Another element of
Ms. Hunt’s case is to present a logical sequence of cause and effect connecting the
vaccinations to either the onset of Elijah’s multiple sclerosis or the worsening of
Elijah’s multiple sclerosis. This element is the second prong of the three-
part Althen test and the fifth prong of the six-part Loving test.
Simply as a matter of logic, because Ms. Hunt has not established the
general proposition that one of the relevant vaccines can worsen multiple sclerosis,
she also cannot establish the specific proposition that one of the vaccines did
worsen Elijah’s multiple sclerosis. See Veryzer v. Sec’y of Health & Human
Servs., 100 Fed. Cl. 344, 352-53 (2011) (describing general causation and specific
causation), aff’d without op., 475 Fed. Appx. 765 (Fed. Cir. 2012); Caves, 100
Fed. Cl. at 145 (discussing the logical relationship between Althen prong one
and Althen prong two). Similarly, the problems with the temporal interval prevent
a conclusion that a vaccine worsened Elijah’s multiple sclerosis. Koehn v. Sec'y of
Health & Human Servs., 773 F.3d 1239, 1243 (Fed. Cir. 2014) (affirming
judgment denying compensation on the ground that petitioner did not establish a
proximate temporal relationship). Thus, Ms. Hunt cannot meet her burden on this
element.
Nevertheless, additional analysis is merited because Ms. Hunt is relying
upon Dr. Mattson, who has assisted in caring for Elijah for many years. The
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Federal Circuit has instructed special masters to consider carefully the opinions of
treating doctors: “treating physicians are likely to be in the best position to
determine whether ‘a logical sequence of cause and effect show[s] that the
vaccination was the reason for the injury.’” Capizzano, 440 F.3d at 1326,
quoting Althen, 418 F.3d at 1280.
However, in this case the factual bases for deferring to Dr. Mattson simply
because he treated Elijah appear to be absent. Dr. Mattson, who specializes in
treatment of multiple sclerosis (Tr. 13-14), stated: “We don’t know the cause” of
ADEM and multiple sclerosis. Tr. 102. He continued that for ADEM, “we have
things that we assume are triggering it. . . . [But], in general we don’t know why
because a lot of people have the same triggers that don’t ever end up getting
ADEM or MS.” Tr. 102-03.22 The literature also notes that the etiology for
multiple sclerosis is unknown. Exhibit D (Noseworthy) at 942 (“the sequence of
events that initiates the disease remains largely unknown”); exhibit F (Frank
DeStephano et al., Vaccinations and Risk of Central Nervous System
Demyelinating Diseases in Adults, 60 Arch Neurology 504 (2003)) at 504
(“Unknown environmental factors, including certain infections, are also suspected
to be involved in its pathogenesis”).
When the medical community does not understand what causes a disease,
how can a treating doctor offer a reliable opinion about whether a vaccination
contributed to the disease’s course? Dr. Mattson was specifically asked whether
his first-hand experience as Elijah’s treating doctor gave him an advantage in
identifying the cause of Elijah’s multiple sclerosis. Dr. Mattson responded that it
did not. Tr. 152.
Dr. Mattson’s forthright assessment that his stature as a treating doctor did
not give him special insights into the cause of Elijah’s multiple sclerosis added to
his credibility as a witness. He was believable, at times, because he acknowledged
22 Dr. Sriram discussed three different theories for the pathogenesis of multiple sclerosis.
Tr. 174-75. He testified that in his patients with multiple sclerosis, “in most of my cases, we do
not have a cause.” Tr. 175.
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his lack of knowledge. Tr. 23, 102.23 But the same admissions leads to a finding
that the petitioner’s proof on this particular prong is lacking.
The admitted lack of knowledge about the causes of multiple sclerosis lies at
the heart of the finding that Dr. Mattson was not persuasive in opining that
vaccinations can worsen multiple sclerosis. The finding that Dr. Mattson was not
persuasive on this specific matter is not intended to be viewed as a depreciation of
his abilities as Elijah’s doctor. Dr. Mattson has won awards from a statewide
multiple sclerosis organization. Exhibit 27 (curriculum vitae) at 2. Additionally,
he appeared to express most of his opinions with sincerity.
However, neither a doctor’s sincerity nor vaunted experience necessarily
makes the expert persuasive. See Doyle v. Sec’y of Health & Human Servs., 92
Fed. Cl. 1, 8 (2010). The doctor’s experience in treating the vaccinee is one factor,
although a very important factor, in considering the value of the doctor’s opinion.
In Bazan, the petitioner presented the opinion of her treating neurologist and
Dr. Hansen opined that the tetanus-diphtheria vaccination can cause a
demyelinating disease to appear within 11 hours of vaccination. The special
master did not credit this testimony for several reasons, including the conflicting
testimony from Dr. Sriram, who opined that 10-14 days were required. Bazan, 539
F.3d at 1353. The Federal Circuit held that the special master did not commit an
error in determining “that Dr. Sriram’s testimony was more credible and probative
than that of Dr. Hansen.” Id. at 1354.
Bazan illustrates the principle that a special master is not required, as a
matter of law, to agree with the testimony of a treating doctor. The example
in Bazan limits the Federal Circuit’s statement that “treating physicians are likely
to be in the best position to determine” whether the vaccine injured the
person. Capizzano, 440 F.3d at 1326. Thus, after Capizzano, in all cases, the
special maser must consider carefully the views of the treating doctor. In some
cases, the testimony of a treating doctor may be persuasive. In other cases, the
testimony of a treating doctor is not persuasive. See Snyder v. Secʼy of Health &
23 On the other hand, Dr. Mattson’s testimony that he made a simple mistake when he
wrote in his first report that Elijah’s experienced neurologic problems within a day of
vaccination was less believable. His demeanor suggested uneasiness about this opinion. Apart
from his demeanor, Dr. Mattson also conceded that Elijah’s dizziness and unsteadiness were
neurologic problems, albeit “nonspecific” ones. Tr. 115.
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Human Servs., 88 Fed. Cl. 706, 745 n.67 (2009) (indicating that testimony from a
treating doctor is not sacrosanct and may be rebutted).
Bazan resembles Ms. Hunt’s case in several respects. In both cases, the
petitioner relied upon the opinion of a doctor who treated the injured person. In
both cases, the petitioner asserted a theory that a vaccine adversely affected the
recipient’s central nervous system. In both cases, the manifestation of this harm
occurred within approximately 24 hours. Finally, in both cases, the Secretary
relied upon the opinion of Dr. Sriram, who stated, among other points, that the
manifestation happened too quickly. Ms. Hunt’s attempts to distinguish Bazan
(see Pet’r’s Reply at 14) were conclusory. The outcome in Bazan supports (but
does not require) the same outcome in Ms. Hunt’s case.24
For all these reasons, Ms. Hunt has not met her burden of presenting
persuasive evidence showing a logical sequence of cause and effect beginning with
the April 20, 2011 vaccinations and the course of Elijah’s multiple sclerosis. She
did not establish the vaccinations either caused or significantly aggravated the
multiple sclerosis. This finding is another reason why compensation must be
denied to Ms. Hunt.
D. Worsening
The remaining three prongs of the Loving test concerns Elijah’s condition.
Because of the previous findings, this analysis can be relatively brief.
1. Health before Vaccination
Before his April 20, 2011 vaccinations, Elijah had not suffered any overt
problems that were diagnosed. But, he had two symptoms that, retrospectively,
could be seen as manifestations of an undiagnosed episode of multiple sclerosis.
These were numbness in his dominant (left) hand and double vision. At the time
24 Although the Federal Circuit’s legal determinations constitute binding precedent in the
Vaccine Program, the determination that the special master was neither arbitrary nor capricious
in finding that 11 hours was too quick an interval for a tetanus-diphtheria vaccine to cause a
demyelinating disease depended upon the evidentiary record in that case. If there were a
different evidentiary record, the outcome might be different because a “special master’s task is to
make a factual determination of causation based on the evidence in a particular case.” Lampe,
219 F.3d 1357, 1366 (Fed. Cir. 2000). But, in weighing the evidence, special masters may use
their “accumulated expertise.” Lampe, 219 F.3d at 1362 (quoting Hodges v. Sec’y of Health &
Human Servs., 9 F.3d 959, 961(Fed. Cir. 1993))
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of his vaccination, his cerebral spinal fluid contained antibodies, although they
were not detected as oligoclonal bands until after the vaccination.
2. Health after Vaccination
Following the April 20, 2011 vaccinations, Elijah’s health declined. He
required hospitalization for seven days during which he was diagnosed as having
ADEM. Approximately, six months later, Elijah suffered another attack during
which the disease “declared” itself as being multiple sclerosis.
More recently, Elijah has been relatively healthy. Medications appear to be
preventing additional attacks.
3. Whether there was a “Significant Aggravation”
Elijah’s health has been worse after the April 20, 2011 vaccinations than he
was before the vaccinations. But, when the record is viewed as a whole, there is
not persuasive evidence that any vaccine caused the worsening.
VI. Conclusion
Elijah suffers from multiple sclerosis. Like anyone suffering from a
permanent disease, he deserves sympathy and compassion. Yet, Congress
restricted Vaccine Program compensation to people who establish that a vaccine
caused or significantly aggravated their illnesses. Ms. Hunt has not established the
legal requirements. Thus, her request for compensation must be DENIED.
IT IS SO ORDERED.
s/ Christian J. Moran
Christian J. Moran
Special Master
39

================================================================================
DOCUMENT 2: USCOURTS-cofc-1_12-vv-00232-1
Date issued/filed: 2015-08-31
Pages: 24
Docket text: Docketed for Administrative Purposes PUBLIC DECISION (Originally filed: 8/13/2015) regarding 71 Order on Motion for Review, Sealed Opinion/Order. Signed by Judge Lydia Kay Griggsby. (jt1) Copy to parties.
--------------------------------------------------------------------------------
Case 1:12-vv-00232-LKG Document 79 Filed 08/31/15 Page 1 of 24
In the United States Court of Federal Claims
No. 12-232V
Filed Under Seal: August 13, 2015
Reissued for Publication: August 31, 2015*
)
JACQUELINE HUNT, legal guardian of )
a minor child, ELIJAH MCLEOD, ) National Childhood Vaccine Injury Act of
) 1986 (“Vaccine Act”), 42 U.S.C. §
Petitioner, ) 300aa–1 to –34 (2012); Varicella Vaccine;
) Tetanus-Diphtheria Acellular Pertussis
v. ) (“Tdap”) Vaccine; Pneumococcal
) Vaccine; Multiple Sclerosis; Acute
SECRETARY OF HEALTH AND ) Disseminated Encephalomyelitis
HUMAN SERVICES, ) (ADEM); Causation; Significant
) Aggravation; Timing.
Respondent. )
)
Daniel H. Pfeifer, Counsel of Record, South Bend, Ind., for petitioner.
Heather L. Pearlman, Senior Trial Attorney, Voris E. Johnson, Jr., Assistant Director,
Vincent J. Matanoski, Deputy Director, Rupa Bhattacharyya, Director, Benjamin C. Mizer,
Principal Deputy Assistant Attorney General, United States Department of Justice, Washington,
DC, for respondent.
MEMORANDUM OPINION AND ORDER
I. INTRODUCTION
Petitioner, Jacqueline Hunt, filed a motion for review of a February 23, 2015, special
master decision denying her claim for compensation under the National Childhood Vaccine
Injury Act of 1986 (“Vaccine Act”), 42 U.S.C. § 300aa–1 to –34 (2012). Petitioner alleges that
her minor grandson suffered from acute disseminated encephalomyelitis and multiple sclerosis as
the result of tetanus-diphtheria acellular pertussis (“Tdap”), meningococcal and varicella
* This Memorandum Opinion and Order was originally filed under seal August 13, 2015 (docket entry
71). The parties were given an opportunity to advise the Court of their views with respect to what
information, if any, should be redacted. The parties filed a joint status report on August 28, 2015 (docket
entry 73) stating that they agreed there is no need for redactions. Accordingly, the Court is reissuing its
Memorandum Opinion and Order as originally filed.

Case 1:12-vv-00232-LKG Document 79 Filed 08/31/15 Page 2 of 24
vaccinations that he received on April 20, 2011. For the reasons set forth below, the Court
DENIES petitioner’s motion for review and SUSTAINS the decision of the special master.
II. FACTUAL AND PROCEDURAL BACKGROUND1
A. Factual Background
The medical history of petitioner’s grandson, Elijah McLeod (“Elijah”), is not in dispute
and can be briefly summarized. Elijah, age 15, suffers from multiple sclerosis. Hunt v. Sec’y of
Health & Human Servs., No. 12-232V, 2015 WL 1263356, at *1 (Fed. Cl. Spec. Mstr. Feb. 23,
2015).
In the fall of 2010, when Elijah was around eleven years old, he started using his right
hand more than his left (dominant) hand. Dec. at *4. According to subsequent medical history
obtained by Elijah’s treating physician, David H. Mattson, M.D., and Elijah’s own testimony,
Elijah also previously experienced numbness in his arm which he attributed to a sports injury.
Id. at 7; Tr. 257. In addition, in February 2011, Elijah began having double vision. Dec. at *2.
Elijah did not seek medical attention for these conditions. Id. at 7.
On April 20, 2011, Elijah received booster vaccinations, including the tetanus-diphtheria
acellular pertussis (“Tdap”), varicella, and meningococcal vaccines. Id. at *3; Ex. 10 at 6. The
next day, Elijah became ill and his mother took him to the hospital emergency room after he
vomited and reported feeling dizzy and off-balance. Dec. at *3. Elijah was assessed with having
a localized reaction to a vaccination and he was not admitted to the hospital. Id.
On April 22, 2011, Elijah was still not feeling well and his grandmother brought him
back to the hospital emergency room. Id. A CT scan of Elijah’s brain revealed at least two areas
of hypodensity and Elijah was admitted to the hospital. Id. A nurse’s assessment from that date
shows that Elijah “was acting like he had a stroke.” Id.
1 The facts recounted in this Memorandum Opinion and Order are taken from the special master’s
February 23, 2015, decision in Hunt v. Sec’y of Health & Human Servs., No. 12-232V, 2015 WL
1263356 (Fed. Cl. Spec. Mstr. Feb. 23, 2015) (“Dec. at __”), the transcript of the hearing before the
special master held on January 9, 2014 (“Tr. __”), petitioner’s motion for review (“Pet. Mot. at ___”), and
respondent’s response to petitioner’s petition for review (“Resp. Mot. at ___”). Except where otherwise
noted, the facts recited here are undisputed.
2

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On April 23, 2011, pediatric neurologist Samira El-Zind, M.D. evaluated Elijah. Id. at
*4. According to the medical history taken by Dr. El-Zind, Elijah’s mother reported concern that
Elijah had been using his right (non-dominant) hand for the past seven months and that he had
experienced double vision for the past two months. Id. Prior to performing an MRI and other
tests, Dr. El-Zind’s impression was that Elijah had “possible acute disseminating
encephalomyelitis with [a] post-immunization reaction.” Id. (brackets original). A subsequent
MRI performed on April 23, 2011, showed large areas of abnormal signals, which the radiologist
interpreted as:
[L]ikely related to acute disseminated encephalomyelitis (ADEM), seen in
postvaccination settings. A demyelinating process such as multiple sclerosis is
felt to be much less likely.
Id. A lumbar puncture also performed on that day revealed two or more oligoclonal bands in
Elijah’s cerebrospinal fluid (“CSF”). Id. Elijah began a course of intravenous steroids and
physical therapy which helped his symptoms. Id.; Tr. at 51. Elijah was discharged from the
hospital on April 29, 2011. Dec. at *4. At that time, his diagnosis appeared to be consistent with
ADEM, although multiple sclerosis remained a differential diagnosis. Id.
A few weeks later, on May 16, 2011, Elijah had a second MRI. Id. at *5. This MRI
showed a new small lesion on Elijah’s brain. Id. The interpreting radiologist compared the
second MRI with Elijah’s previous MRI and concluded that the MRI’s findings were consistent
with ADEM. Id. But, after consulting with Dr. El-Zind, the radiologist also noted that “the
possibility of multiple sclerosis is not excluded.” Id. After another CSF study showed
oligoclonal bands “suggesting multiple sclerosis,” Elijah was discharged from the hospital on
May 21, 2011, with a diagnosis of “[multiple sclerosis] flair.” Id. at *6.
On June 10, 2011, neurologist Dr. Mattson evaluated Elijah. Id. During this visit, Elijah
reported the trouble with his left hand, but he did not tell Dr. Mattson about the past history of
double vision. Id. Dr. Mattson considered Elijah to have ADEM; but noted that the presence of
oligoclonal bands “increase[s] the risk that [the condition] will go on to be multiple sclerosis.”
Id.
On June 20, 2011, Elijah saw Dr. El-Zind again. Id. An MRI showed that “the number
and distributions of the lesions appears stable” and that “there were ‘three new foci of abnormal
3

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enhancement.’” Id. The interpreting radiologist reported that the lesions are “nonspecific but
consistent with the expected changes of evolving demyelinating lesions such as can be seen with
[multiple sclerosis] or ADEM.” Id.
After experiencing headaches, body aches, and a stomach ache, Elijah returned to the
hospital emergency room again on August 17, 2011. Id. A fourth MRI was performed on
August 18, 2011, and showed more lesions. Id. The interpreting radiologist found the MRI
results to be consistent with multiple sclerosis. Id.
On August 26, 2011, Elijah returned to see Dr. Mattson with a copy of his most recent
MRI. Id. at *7. At that time, Dr. Mattson stated that he felt “very comfortable that this has been
declared as multiple sclerosis.” Id. On December 23, 2011, Dr. Mattson saw Elijah for a follow-
up visit, and he concluded that Elijah had been suffering from pediatric onset multiple sclerosis
of “approximately 8 months duration.” Id. Dr. Mattson continues to treat Elijah and with
treatment, Elijah has not had any subsequent severe flares of multiple sclerosis. Id. at 7.
B. Procedural History
The relevant procedural history is set forth in the special master’s decision. In short, on
April 10, 2012, the prior petitioner in this matter, Tomika McLeod, filed a petition for vaccine
compensation on behalf of Elijah under the Vaccine Act. Id. at *1 n. 2. In her petition, Ms.
McLeod alleged that Elijah suffered from ADEM and multiple sclerosis as the result of Tdap,
meningococcal, and varicella booster vaccinations that Elijah received on April 20, 2011. Id. at
*1.
Following the submission of medical records and expert reports, the special master
convened an entitlement hearing on January 9, 2014. Id. at *9. During the hearing, Elijah and
Dr. Mattson testified on behalf of petitioner, and the government’s medical expert, Dr. Sriram,
also testified on behalf of respondent. See generally Transcript of Hearing, dated January 9,
2014. On January 10, 2014, the caption of this case was amended to add Jacqueline Hunt as the
petitioner. Id. at *1 n. 2. On February 23, 2015, the special master entered a decision denying
petitioner’s request for compensation. See generally Dec.
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On March 25, 2015, petitioner filed a motion for review of the special master’s decision
in this Court. See generally Pet. Mot. The Secretary of Health and Human Services filed a
response to petitioner’s motion for review on April 24, 2015. See generally Resp. Mot.
C. The Special Master’s Decision
On February 23, 2015, the special master issued a decision denying petitioner’s claim for
compensation under the Vaccine Act. See generally Dec. In the decision, the special master
determined, as an initial matter, that the onset of Elijah’s multiple sclerosis predated the
vaccinations. Id. at *10-12. Relying upon this Court’s decision in Paluck, the special master
then looked for evidence of multiple sclerosis before the vaccinations. Id. at *10; Paluck v.
Sec’y of Health & Human Servs., 104 Fed. Cl. 457, 469 (2012) (remanding case), rev’ing after
remand, 113 Fed. Cl. 210 (2013), aff’d, 786 F.3d 1373 (Fed. Cir. 2015). And so, the special
master concluded that the case presented was one of alleged significant aggravation, rather than
causation-in-fact. Id. at *12.
In this regard, the special master found that Elijah experienced at least two symptoms that
could indicate of a problem with his central nervous system prior to the vaccinations. First, in
2010, Elijah developed weakness in his dominant hand. Dec. at *12. Second, Elijah experienced
episodes of double vision beginning in February 2011. Id. Based upon this medical evidence,
the special master determined that Elijah experienced clinical symptoms of multiple sclerosis
before the April 20, 2011 vaccinations. Id. The special master also observed that Elijah’s
treating physician, Dr. Mattson, conceded on cross-examination that Elijah suffered from
subclinical multiple sclerosis before the vaccinations. Id. And so, the special master concluded
that petitioner’s causation-in-fact claim was untenable given the finding of preexisting multiple
sclerosis and that petitioner may only pursue her significant aggravation theory. Id. at *14.
With respect to petitioner’s significant aggravation claim, the special master similarly
found that petitioner failed to meet her burden of proof. Id. at *14-25. In particular, the special
master found that petitioner’s medical theory−that vaccines can aggravate multiple sclerosis−“is
contrary to an unrebutted epidemiologic study on this precise question.” Id. at *1. The special
master also found that petitioner had not met her burden of proof to show how any of the specific
vaccines that Elijah received can cause or significantly aggravate multiple sclerosis. Id. at *18.
5

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Specifically, the special master rejected as unpersuasive two medical theories put forward
by petitioner to show a connection–via molecular mimicry or bystander activation–between
multiple sclerosis and the relevant vaccines. Id. at *15-18. In this regard, the special master
noted that none of the medical literature relied upon by petitioner connected the relevant
vaccines to multiple sclerosis. See id. at *15. The special master also noted that one medical
study submitted in the case, the Zorzon study, pertained to multiple sclerosis and the varicella
vaccine. Id. at *16. But, the special master accorded the Zorzon study no weight, because
petitioner did not elicit any testimony regarding that study or address the study in her post-
hearing briefs. Id. And so, the special master concluded that petitioner did not establish, by a
preponderance of the evidence, that any of the vaccines Elijah received can cause, or
significantly aggravate, multiple sclerosis. Id. at *18.
Lastly, with respect to the timing of the onset of Elijah’s alleged injury, the special
master also determined that the biologic process proposed by petitioner would take at least three
days following the vaccinations. Id. at *1. In this regard, the special master also found that this
threshold has not been met in this case, because Elijah first exhibited symptoms one day after
receiving the vaccinations. Id. And so, the special master concluded that petitioner failed to
meet her burden of proof regarding the appropriate temporal interval for the onset of Elijah’s
symptoms. Id. at 2.
Petitioner, alleging error, seeks review of the special master’s decision.
III. STANDARDS FOR DECISION
A. Standard Of Review
The United States Court of Federal Claims has jurisdiction to review the record of the
proceedings before a special master and, upon such review, may:
(A) uphold the findings of fact and conclusions of law of the special master and
sustain the special master’s decision;
(B) set aside any findings of fact or conclusions of law of the special master found
to be arbitrary, capricious, an abuse of discretion, or otherwise not in accordance
with law and issue its own findings of fact and conclusions of law; or
(C) remand the petition to the special master for further action in accordance with
the court’s direction.
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42 U.S.C. § 300aa–12(e)(2).
The special master’s determinations of law are reviewed de novo. Andreu ex rel. Andreu
v. Sec’y of Dep’t of Health & Human Servs., 569 F.3d 1367, 1373 (Fed. Cir. 2009). The special
master’s findings of fact are reviewed for clear error. Id.; see also Broekelschen v. Sec’y of
Health & Human Servs., 618 F.3d 1339, 1345 (Fed. Cir. 2010) (“We uphold the special master’s
findings of fact unless they are arbitrary or capricious.”). In addition, a special master’s findings
regarding the probative value of the evidence and the credibility of witnesses will not be
disturbed so long as they are “supported by substantial evidence.” Doe v. Sec’y of Health &
Human Servs., 601 F.3d 1349, 1355 (Fed. Cir. 2010) (citing Whitecotton ex rel. Whitecotton v.
Sec’y of Health & Human Servs., 81 F.3d 1099, 1105 (Fed. Cir. 1996), on remand from Shalala
v. Whitecotton, 514 U.S. 268 (1995)); see also Porter v. Sec’y of Health & Human Servs., 663
F.3d 1242, 1249 (Fed. Cir. 2011) (providing the standard for an off-Table injury). This “level of
deference is especially apt in a case in which the medical evidence of causation is in dispute.”
Hodges v. Sec’y of the Dep’t of Health & Human Servs., 9 F.3d 958, 961 (Fed. Cir. 1993).
B. Causation And Significant Aggravation
Pursuant to the Vaccine Act, the Court shall award compensation if a petitioner proves,
by a preponderance of the evidence, all of the elements set forth in 42 U.S.C. § 300aa–11(c)(1),
unless there is a preponderance of evidence that the illness is due to factors unrelated to the
administration of the vaccine. 42 U.S.C. § 300aa–13(a)(1). A petitioner can recover either by
proving an injury listed on the Vaccine Injury Table (“Table”) or by proving causation-in-fact.
See 42 U.S.C. §§ 300aa–11(c)(1)(C).
To establish a prima facie case when proceeding on a causation-in-fact theory, as
petitioner seeks to do in this matter, a petitioner must “prove, by a preponderance of the
evidence, that the vaccine was not only a but-for cause of the injury but also a substantial factor
in bringing about the injury.” Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344, 1352
(Fed. Cir. 1999). “[T]o show that the vaccine was a substantial factor in bringing about the
injury, the petitioner must show ‘a medical theory causally connecting the vaccination and the
injury.’” Id. at 1352–53 (quoting Grant v. Sec’y of Health & Human Servs., 956 F.2d 1144,
1148 (Fed. Cir. 1992) (per curiam)). In other words, “[t]here must be a ‘logical sequence of
cause and effect showing that the vaccination was the reason for the injury,’” id. at 1353 (quoting
7

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Grant, 956 F.2d at 1148), and “[t]his ‘logical sequence of cause and effect’ must be supported by
a sound and reliable medical or scientific explanation.” Knudsen ex rel. Knudsen v. Sec’y of the
Dep’t of Health & Human Servs., 35 F.3d 543, 548 (Fed. Cir. 1994) (citing Jay v. Sec’y of Dep’t
of the Dep’t of Health & Human Servs., 998 F.2d 979, 984 (Fed. Cir. 1993)); see also 42 U.S.C.
§ 300aa–13(a)(1) (“The special master or court may not make such a finding based on the claims
of a petitioner alone, unsubstantiated by medical records or by medical opinion.”). However,
medical or scientific certainty is not required. Knudsen, 35 F.3d at 548–49.
In Althen, the Federal Circuit set forth three elements that a petitioner must provide to
prove causation-in-fact:
(1) a medical theory causally connecting the vaccination and the injury; (2) a
logical sequence of cause and effect showing that the vaccination was the reason
for the injury; and (3) a showing of a proximate temporal relationship between
vaccination and injury.
Althen v. Sec'y of Health & Human Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005). All three
prongs “must cumulatively show that the vaccination was a ‘but-for’ cause of the harm, rather
than just an insubstantial contributor in, or one among several possible causes of, the harm.”
Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352, 1355 (Fed. Cir. 2006).
With respect to a significant aggravation claim, the Vaccine Act defines significant
aggravation as “any change for the worse in a preexisting condition which results in markedly
greater disability, pain, or illness accompanied by substantial deterioration of health.” 42 U.S.C.
§ 300aa–33(4). In off-Table cases, like here, additional proof is necessary for a petitioner to
prevail on a significant aggravation claim. 42 U.S.C. § 300aa-11(c)(1)(C).
In this regard, the Federal Circuit has held that to establish a prima facie case for the
significant aggravation of an off-Table injury, a petitioner must show by preponderant proof:
(1) the person’s condition prior to administration of the vaccine, (2) the person’s
current condition (or the condition following the vaccination if that is also
pertinent), (3) whether the person’s current condition constitutes a “significant
aggravation” of the person’s condition prior to the vaccination, (4) a medical
theory causally connecting such a significantly worsened condition to the
vaccination, (5) a logical sequence of cause and effect showing that the
vaccination was the reason for the significant aggravation, and (6) . . . a
proximate temporal relationship between the vaccination and the significant
aggravation.
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W.C. v. Sec’y of Health & Human Servs., 704 F.3d 1352, 1357 (Fed. Cir. 2013) (quoting Loving
ex. rel. Loving v. Sec’y of Health & Human Servs., 86 Fed. Cl. 135, 144 (2009)). The United
States Court of Appeals for the Federal Circuit further makes clear that “a petitioner in an off-
[T]able case must show the vaccine actually caused the significant aggravation—not just that,
accepting petitioner's medical theory as sound, the person's condition worsened within a
medically-acceptable time frame.” Id.
If a petitioner establishes a prima facie case, the burden shifts to the respondent to show,
by a preponderance of the evidence, that the injury was caused by a factor unrelated to the
vaccine. See 42 U.S.C. § 300aa-13(a)(1)(B); Shalala, 514 U.S. at 270–71. But, regardless of
whether the burden of proof ever shifts to the respondent, the special master may consider the
evidence presented by the respondent in determining whether the petitioner has established a
prima facie case. See Stone v. Sec'y of Health & Human Servs., 676 F.3d 1373, 1379 (Fed. Cir.
2012) (“[E]vidence of other possible sources of injury can be relevant not only to the ‘factors
unrelated’ defense, but also to whether a prima facie showing has been made that the vaccine
was a substantial factor in causing the injury in question.”); de Bazan v. Sec’y of Health &
Human Servs., 539 F.3d 1347, 1353 (Fed. Cir. 2008) (“The government, like any defendant, is
permitted to offer evidence to demonstrate the inadequacy of the petitioner’s evidence on a
requisite element of the petitioner’s case[-]in-chief.”).
IV. LEGAL ANALYSIS
The petitioner enumerates five objections to the special master’s decision. First,
petitioner argues that the special master erred by considering evidence of preexisting multiple
sclerosis before considering her causation-in-fact claim. Pet. Mot. at 2-5. Second, petitioner
also argues that the special master abused his discretion by failing to consider probative evidence
supporting her causation-in-fact claim. Id. at 5-6. Third, petitioner contends that the special
master’s determination that Elijah suffered from multiple sclerosis prior to the vaccinations was
arbitrary and capricious. Pet. Mot. at 6-9. Fourth, petitioner contends that the special master
erred in analyzing her significant aggravation claim, by imposing a heightened burden of proof
for the medical theory, timing, and logical sequencing prongs under Althen and Loving. Pet.
Mot. at 9-15, 18-21. Lastly, petitioner argues that the special master erred in determining the
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medically-appropriate time period for the onset of Elijah’s symptoms after the vaccinations. Pet.
Mot. at 15-18.
For the reasons discussed below, the record evidence shows that the special master
committed several errors in analyzing petitioner’s claim. But, the special master, nonetheless,
correctly determined that petitioner had not established that she is entitled to compensation under
the Vaccine Act. And so, the Court sustains the decision of the special master.
A. The Special Master Erred In Analyzing Petitioner’s Causation Claim
1. The Special Master Erred In Making A Preliminary Diagnosis
As an initial matter, petitioner correctly argues that the special master erred in making a
preliminary determination regarding the pre-vaccination status of Elijah’s health, before applying
the analysis required under Althen. Pet. Mot. at 2-3; see also Althen, 418 F.3d at 1278. At the
outset of this case, the special master determined that the first matter to be resolved was the
status of Elijah’s health prior to the vaccines. Dec. at *10. And so, the special master
determined that Elijah “manifested symptoms of multiple sclerosis before the vaccination[s].”
Id.
The special master erred in making this preliminary determination. In Broekelschen, the
United States Court of Appeals for the Federal Circuit held that, when there is disagreement
about the very nature of a petitioner’s injury, a special master does not err by preliminarily
determining which of two possible and different medical diagnoses was correct. 618 F.3d at
1345-46. Similarly, in Lombardi v. Sec’y of Health and Human Servs., when the petitioner in
that case failed to show “the very existence of any specific injury,” the United States Court of
Appeals for the Federal Circuit held that the special master could first determine what injury, if
any, the petitioner had suffered after receiving the vaccine. 656 F.3d 1343, 1353 (Fed. Cir.
2011). The Lombardi and Broekelschen cases are, however, distinguishable from this matter.
Here, there is no disagreement about the nature of Elijah’s injuries. Dec. at *4-10, *17.
In fact, both parties agree that Elijah has experienced neurological symptoms involving the
central nervous system. Pet. Mot. at 8-9; Resp. Mot. at 2-5. Moreover, while petitioner alleges
that the vaccines initially caused ADEM, she also acknowledges that “ADEM is part of the
spectrum of inflammatory demyelinating diseases that encompass ADEM and multiple
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sclerosis.” Id. at 3. And so, given the general agreement among the parties about the nature of
Elijah’s injury, there was no legal or factual basis under either Broekelschen or Lombardi for the
special master to determine, as a preliminary matter, that Elijah suffered from multiple sclerosis.
Broekelschen, 618 F.3d at 1345-46; Lombardi, 656 F.3d 1353.
The special master similarly erred in determining that Elijah had multiple sclerosis prior
to the vaccinations, before fully analyzing petitioner’s causation-in-fact claim. Relying upon this
Court’s decision in Paluck, the special master looked for evidence of multiple sclerosis that may
have been present before the vaccinations at the outset of the case. See Paluck, 104 Fed. Cl. at
469 (remanding to special master), rev’ing decision after remand, 113 Fed. Cl. 210, 225 (2013),
aff’d, 786 F.3d 1373 (Fed. Cir. 2015); Dec. at *10. In doing so, the special master found
evidence of preexisting multiple sclerosis. Dec. at *10. And so, he concluded that “[t]he legal
consequence of finding that Elijah suffered clinical symptoms of multiple sclerosis and had
(undetected) laboratory evidence of multiple sclerosis means that [petitioner] may pursue her
significant aggravation theory only.” Id. at *12.
The special master’s reliance upon Paluck to bypass the analysis required under Althen in
reaching his determination is misplaced. In Paluck, this Court observed that, if symptoms of an
illness were manifest pre-vaccination, the case involves a significant aggravation claim. Paluck,
104 Fed. Cl. at 469. But, the Court does not read the Paluck decision to hold that a special
master may completely bypass the framework set forth in Althen in determining whether such a
preexisting injury exists. See id. at 470-83. Rather, in Paluck, the Court observed that the
special master in that case correctly conducted the analysis under Althen in considering the
petitioner’s claims. Id. at 469. Because the special master did not fully analyze petitioner’s
causation-in-fact claim under Althen before turning to the question of whether the vaccines
caused a significant aggravation of Elijah’s injury, he erred in analyzing petitioner’s causation-
in-fact claim. Id.; Althen, 418 F.3d. at 1278.
2. The Special Master Abused His Discretion By Failing To Consider
Evidence Supporting Petitioner’s Causation-In-Fact Claim
The special master also erred by failing to consider probative evidence supporting
petitioner’s causation-in-fact claim. In her petition for review, petitioner alleges that the special
master abused his discretion by failing to consider probative evidence and testimony supporting
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her claim that the vaccinations caused Elijah to develop ADEM and later multiple sclerosis. Pet.
Mot. at 5-6. The Court agrees.
This Court has long recognized that special masters have broad authority in building a
record for decision in vaccine cases and enjoy “flexible and informal standards of admissibility
of evidence.” Davis v. Sec’y of Health & Human Servs., 94 Fed. Cl. 53, 65 (2010), aff’d in part,
rev’d on other grounds, 420 F. App’x 973 (Fed. Cir. 2011) (quoting 42 U.S.C. § 300aa–
12(d)(2)(B)). However, “that authority may not be used in a way that deprives a party of
procedural rights provided by the Vaccine Act and the Vaccine Rules.” Simanski v. Sec’y of
Health & Human Servs., 671 F.3d 1368, 1385 (Fed. Cir. 2012). In this regard, Vaccine Rule
8(b)(1) directs the special master to consider “all relevant and reliable evidence.” Vaccine Rule
8(b)(1); see also 42 U.S.C. § 300aa–13(b)(1) (The special master shall consider certain medical
information “in addition to all other relevant medical and scientific evidence.”); cf. Fed. R. Evid.
402 (“Irrelevant evidence is not admissible.”). And so, while “the special master need not
address every snippet of evidence adduced in the case, . . . he cannot dismiss so much contrary
evidence that it appears that he ‘simply failed to consider genuinely the evidentiary record before
him.’” Paluck, 104 Fed. Cl. at 467 (quoting Campbell v. Sec’y of Health & Human Servs., 97
Fed. Cl. 650, 668 (2011)) (citation omitted).
The record also shows that the special master did not fully consider evidence in support
of petitioner’s causation-in-fact claim that the vaccinations caused post-vaccinal ADEM. During
the proceedings before the special master, petitioner submitted medical records showing that six
treating physicians diagnosed Elijah with post-vaccinial ADEM. See Dec. at *6, *8; Ex. 10 at 3,
5-9; Ex. 12 at 252-53. Petitioner also submitted six pieces of medical literature to support her
claim that vaccines can trigger ADEM. See generally Ex. 29; Ex. 30; Ex. 31; Ex. 36; Ex. 37. In
particular, one piece of medical literature, the Menge article, refers to the pertussis vaccine−one
of the vaccines that Elijah received−as being associated with ADEM. Tr. 68:17-20; Ex. 31 at 2.
Another medical article, the Hartung article, also states that ADEM is known to follow the
diphtheria-tetanus-pertussis (“DTaP”) vaccine, which Elijah also received. Ex. 34 at 2.
By failing to consider this evidence, the special master ignored probative evidence in
support of petitioner’s causation-in-fact claim. As discussed above, while the special master
need not address all evidence, he cannot simply fail to consider the full evidentiary record in the
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case. See Paluck, 104 Fed. Cl. at 467. And so, the special master abused his discretion in failing
to fully consider evidence to support petitioner’s causation-in-fact claim.
B. The Special Master’s Errors Are Harmless Because Petitioner Has Not
Proven Her Causation-In-Fact Claim
While the special master committed several errors in assessing petitioner’s causation-in-
fact claim, those errors are, nonetheless, harmless because petitioner has not proven her claim.
In Althen, the Federal Circuit set forth a three-part test to prove causation-in-fact, requiring a
petitioner to provide:
(1) a medical theory causally connecting the vaccination and the injury; (2) a
logical sequence of cause and effect showing that the vaccination was the reason
for the injury; and (3) a showing of a proximate temporal relationship between
vaccination and injury.
Althen, 418 F.3d at 1278. All three prongs “must cumulatively show that the vaccination was a
‘but-for’ cause of the harm, rather than just an insubstantial contributor in, or one among several
possible causes of, the harm.” Pafford, 451 F.3d at 1355. For the reasons discussed below, the
Althen prongs cumulatively weigh against petitioner’s causation-in-fact claim here.
1. Petitioner Has Not Proven A Logical Sequence
First, petitioner fails to show a logical sequence of cause and effect, showing that the
vaccines were the reason for Elijah’s illness. Althen, 418 F.3d at 1278; Shyface, 165 F.3d at
1353. To establish a prima facie case on a causation-in-fact theory, petitioner must “prove, by a
preponderance of the evidence, that the vaccine was not only a but-for cause of the injury but
also a substantial factor in bringing about the injury.” Shyface, 165 F.3d at 1352. And so,
“[t]here must be a ‘logical sequence of cause and effect showing that the vaccination was the
reason for the injury,’” id. at 1353 (quoting Grant, 956 F.2d at 1148), and “[t]his ‘logical
sequence of cause and effect’ must be supported by a sound and reliable medical or scientific
explanation.” Knudsen, 35 F.3d at 548 (quoting Jay, 998 F.2d at 984); see also 42 U.S.C. §
300aa–13(a)(1) (“The special master or court may not make such a finding based on the claims
of a petitioner alone, unsubstantiated by medical records or by medical opinion.”).
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In this case, there is ample evidence in the record−much of it undisputed−that Elijah
suffered from multiple sclerosis prior to the vaccinations. As a result, the substantial weight of
the evidence shows that the vaccines did not cause his illness.
In this regard, the record evidence shows that Elijah developed weakness in his dominant
hand and experienced episodes of double vision prior to the vaccinations. Dec. at *12. Elijah
also testified that he experienced numbness in his arm and had episodes of double vision prior to
the vaccinations−both recognized symptoms of multiple sclerosis. Tr. 105:15-20, 106:12-18,
260:2-23. During his testimony before the special master, Elijah’s treating physician, Dr.
Mattson, also acknowledged that these two symptoms can be indications of multiple sclerosis.
Tr. 105:15-20, 106:12-18; see also Pet. Mot. at 8.
The record also shows that a medical test conducted shortly after Elijah received the
vaccines indicates that the onset of Elijah’s multiple sclerosis occurred before the vaccinations.
Specifically, a CSF study conducted in May 2011 showed oligoclonal bands in Elijah’s spinal
fluid, “suggesting multiple sclerosis.” Dec. at *5. Both medical experts in this case, Dr. Mattson
and Dr. Sriram, agree that the oligoclonal bands in Elijah’s spinal fluid were likely present
before the administration of vaccines. Tr. 84:3-4, 195:11-15. Most likely for this reason, Dr.
Mattson also acknowledged during his testimony before the special master that Elijah suffered
from subclinical multiple sclerosis before the vaccinations. Tr. 119:13-16.
While petitioner correctly maintains that there is evidence in the record showing that
several physicians diagnosed Elijah with post-vaccinal ADEM, a finding that the onset of
Elijah’s injuries occurred after the vaccinations is simply contradicted by the substantial weight
of all of the evidence.2 Pet. Mot. at 6-7. In fact, while petitioner disagrees that the neurological
2 On April 23, 2011, Dr. El-Zind reported that Elijah had “possible acute disseminating encephalomyelitis
with [a] post-immunization reaction.” Ex. 5 at 12. Radiologist Dr. Allison Lamont’s impression of
Elijah’s April 23, 2011, MRI stated that it was “likely related to acute disseminated encephalomyelitis
(ADEM), seen in post vaccination settings. A demyelinating process such as multiple sclerosis is felt to
be much less likely.” Ex. 5 at 350. Radiologist Dr. Pedro Miro’s interpretation of Elijah’s second MRI
taken on May 16, 2011, stated that “[t]he findings are consistent with the patient’s repeated history of
acute disseminated encephalomyelitis (ADEM).” Ex. 9 at 232. Dr. Lisa Smith, a neurologist, said, “[t]he
etiology for this presentation most closely correlates with [Elijah] receiving his vaccinations prior to the
onset of the disease.” Ex. 10 at 7. Dr. Mattson noted on June 10, 2011, “[Elijah] is certainly to stay away
from vaccinations in the future because that was very likely the triggering event for his multifocal
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symptoms Elijah experienced in 2010 and early 2011 were caused by multiple sclerosis, she,
nonetheless, acknowledges that these symptoms occurred before the vaccinations. Pet. Mot. at
17. Petitioner also fails to explain why these symptoms should not be attributed to Elijah’s
multiple sclerosis. Id. at 8-9. And so, petitioner fails to show, by a preponderance of the
evidence, a logical sequence of cause and effect connecting any one of the vaccines that Elijah
received to his illness.
In addition, petitioner’s other objections to the special master’s finding of preexisting
multiple sclerosis are misplaced. In her motion, petitioner argues that the special master’s
determination that Elijah suffered from multiple sclerosis prior to the vaccinations was arbitrary
and capricious. Pet. Mot. at 6-9; see also Dec. at *9. But, as discussed above, the evidence in
the record supports the special master’s determination that “Elijah suffered clinical symptoms of
multiple sclerosis” prior to the vaccinations. Dec. at *12.
Given this evidence, the special master reasonably concluded that the onset of Elijah’s
injury occurred prior to the vaccinations. The Court will not set aside the special master’s
finding. Broekelschen, 618 F.3d at 1345 (“We uphold the special master’s findings of fact unless
they are arbitrary or capricious.”) (citing Capizzano v. Sec’y of Health & Human Servs., 440 F.3d
1317, 1324 (Fed. Cir. 2006)).
Petitioner also incorrectly argues that the special master erred by considering evidence
presented by the government to show that the onset of multiple sclerosis occurred prior to the
vaccinations during the presentation of her causation-in-fact claim. Pet. Mot. at 2-3. In this
regard, it is well established that evidence of other possible sources of an illness can also be
relevant to a petitioner’s prima facie case. See Stone, 676 F.3d at 1379. For this reason, this
Court has recognized that a special master may consider the evidence presented by the
respondent in determining whether the petitioner has established a prima facie case, regardless of
whether the burden of proof ever shifts to the respondent under the Vaccine Act. Id.
(“[E]vidence of other possible sources of injury can be relevant not only to the ‘factors
demyelination.” Ex. 10 at 3. Dr. Madden’s interpretation of Elijah’s June 21, 2011, MRI included the
comment that “these lesions are nonspecific but consistent with the expected changes of evolving
demyelinating lesions such as can be seen with [multiple sclerosis] or ADEM. There are no new lesions
and this may be more consistent with ADEM . . . .” Ex. 12 at 251.
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unrelated’ defense, but also to whether a prima facie showing has been made that the vaccine
was a substantial factor in causing the injury in question.”); de Bazan, 539 F.3d at 1353 (“The
government, like any defendant, is permitted to offer evidence to demonstrate the inadequacy of
the petitioner’s evidence on a requisite element of the petitioner’s case[-]in-chief.”).
Here, the record shows that the government presented evidence of preexisting multiple
sclerosis to rebut the petitioner’s prima facie case. See Dec. at *11; Ex. A at 3; Respondent’s
Report 10-11, Aug. 29, 2012. Such evidence is certainly relevant to the question of whether
petitioner has proven her prima facie case that vaccines caused Elijah’s injury. And so, the
special master properly considered this evidence within the context of assessing petitioner’s
causation-in-fact claim. See Stone, 676 F.3d at 1379; de Bazan, 539 F.3d at 1353.
In sum, the substantial weight of the record evidence supports the special master’s
finding that the onset of Elijah’s multiple sclerosis occurred before the vaccinations. Given this,
petitioner has not satisfied the logical sequence prong under Althen.
2. Petitioner Has Not Satisfied The Timing Prong
For these same reasons, petitioner also fails to establish a proximate temporal relationship
between vaccinations and the onset of Elijah’s injury. In this regard, this Court has recognized
that, if symptoms arise too soon to be caused by a vaccine, “the temporal relationship is not such
that it is medically acceptable to conclude that the vaccination and the injury are causally
linked.” de Bazan, 539 F.3d at 1352. As discussed above, the record evidence here shows that
Elijah experienced symptoms of multiple sclerosis in the fall of 2010 and again in February
2011, many months before the vaccinations. Dec. at *2. Petitioner does not dispute that these
symptoms occurred prior to the vaccinations. Pet. Mot. at 8-9. Nor does she eliminate any
alternative causes for these symptoms. Id; see also de Bazan, 539 F.3d at 1353 (finding that
when symptoms arise too soon to be caused by a vaccine, they must have an alternative cause
and that it does not raise the burden of proof to require petitioner to eliminate those alternative
causes). And so, petitioner simply has not proven by a preponderance of the evidence that a
temporal relationship exists between the vaccinations and the onset of Elijah’s injury in this case.
de Bazan, 539 F.3d at 1352.
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3. Petitioner Has Not Satisfied The Medical Theory Prong
Because petitioner cannot satisfy the logical sequence or timing prongs under Althen, it is
not necessary to analyze petitioner’s causation-in-fact claim under the medical theory prong. See
W.C., 704 F.3d at 1358 (finding that “[t]he lack of a logical sequence of cause and effect, and the
lack of a ‘medically-acceptable temporal relationship’ between the vaccination and disease
onset” can prevent petitioner from establishing a causation-in-fact claim). Nonetheless, as
discussed below, petitioner also fails to meet her burden under the medical theory prong, because
she has not established a link between any of the vaccines that Elijah received and his injury.
Because the three Althen prongs for a causation-in-fact off-Table case do not
cumulatively show that the vaccinations at issue here were a ‘but-for’ cause of Elijah’s injury,
petitioner has not proven her causation-in-fact claim. And so, as the special master concluded
during the proceedings below, the Court concludes that the case presented here is one of possible
significant aggravation.
C. Petitioner Has Not Proven Her Significant Aggravation Claim
The record evidence also shows that petitioner has not proven her significant aggravation
claim. In her motion for review, petitioner alleges that the special master committed reversible
error by imposing a heightened burden of proof when analyzing her significant aggravation
claim under the medical theory, logical sequence, and temporal relationship prongs set forth in
Loving and Althen. Pet. Mot. at 9-15, 18-21. For the reasons discussed below, the special master
erred in applying the timing and logical sequence prongs under Loving and Althen, but correctly
concluded that petitioner had not proven her significant aggravation claim.
1. The Special Master Properly Analyzed The Medical Theory Prong
As an initial matter, petitioner incorrectly argues that the special master held her to a
heightened burden of proof under the medical theory prong of Althen and Loving. Pet.’s Mot. at
10. As established above, pursuant to the Vaccine Act, a “significant aggravation” involves
“any change for the worse in a preexisting condition which results in markedly greater disability,
pain, or illness accompanied by substantial deterioration of health.” 42 U.S.C. § 300aa–33(4).
In off-Table cases, like here, additional proof is necessary for a petitioner to prevail on a
significant aggravation claim. And so, to prove a prima facie case for the significant aggravation
of an off-Table injury, a petitioner must provide:
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(1) the person’s condition prior to administration of the vaccine, (2) the person’s
current condition (or the condition following the vaccination if that is also
pertinent), (3) whether the person’s current condition constitutes a “significant
aggravation” of the person’s condition prior to the vaccination, (4) a medical
theory causally connecting such a significantly worsened condition to the
vaccination, (5) a logical sequence of cause and effect showing that the
vaccination was the reason for the significant aggravation, and (6) . . . a
proximate temporal relationship between the vaccination and the significant
aggravation.
W.C., 704 F.3d at 1357 (quoting Loving, 86 Fed. Cl. at 144).
In addition, the Vaccine Act requires that petitioners prove causation and significant
aggravation claims “by a preponderance of the evidence,” which can be satisfied “by medical
records or by medical opinion.” 42 U.S.C. § 300aa-13(a)(1). Moreover, the United States Court
of Appeals for the Federal Circuit has recognized that a petitioner’s claim should not be barred
due to a lack of medical literature supporting that theory. Andreu, 569 F.3d at 1378 (“Requiring
‘epidemiologic studies . . . or general acceptance in the scientific or medical communities . . .
impermissibly raises a claimant's burden under the Vaccine Act and hinders the system created
by Congress, in which close calls regarding causation are resolved in favor of injured
claimants.’” (quoting Capizzano, 440 F.3d at 1325-26)). Nonetheless, a petitioner must do more
than demonstrate a “plausible” or “possible” causal link between the vaccination and the injury.
Moberly ex rel. Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1322 (Fed. Cir.
2010). “[N]either a mere showing of a proximate temporal relationship between vaccination and
injury, nor a simplistic elimination of other potential causes of the injury suffices, without more,
to meet the burden of showing actual causation.” Althen, 418 F.3d at 1278. And so, “a
petitioner in an off-[T]able case must show the vaccine actually caused the significant
aggravation–not just that, accepting petitioner’s medical theory as sound, the person’s condition
worsened within a medically-acceptable time frame. W.C., 704 F.3d at 1357 (emphasis
supplied).
In W.C. v. Sec’y of Health & Human Servs., the United States Court of Appeals for the
Federal Circuit held that a special master correctly required the petitioner in that case to provide
specific evidence showing that the vaccine at issue in that case caused a significant aggravation
of the petitioner’s multiple sclerosis through the process of molecular mimicry. 704 F.3d at
1360. In that case, the petitioner argued that the influenza vaccine significantly aggravated his
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multiple sclerosis. Id. at 1355. But, the petitioner did not show that the particular parts of the
influenza virus that had been shown to be linked to multiple sclerosis were actually present in the
vaccine that he received. Id. at 1360-61. For this reason, the United States Court of Appeals for
the Federal Circuit concluded that the petitioner failed to satisfy the medical theory prong. Id. at
1361. The United States Court of Appeals for the Federal Circuit’s decision in W.C. is
instructive here.
In this matter, the special master required petitioner to establish that at least one of the
vaccines Elijah received was capable of−through either molecular mimicry or bystander
activation−causing significant aggravation of multiple sclerosis. Dec. at *15. The United States
Court of Appeals for the Federal Circuit’s holding in W.C. makes clear that the special master
properly applied the standard in evaluating petitioner’s medical theory. Id. And so, petitioner
has not been held to a heightened burden of proof under the medical theory prong in this case.
The special master also correctly determined that petitioner did not satisfy the medical
theory prong, because she put forward no evidence to connect any of the vaccines that Elijah
received to multiple sclerosis. In this regard, the record evidence shows that petitioner failed to
put forward any medical literature or testimony to connect the Tdap, varicella and
meningococcal vaccines with multiple sclerosis. Id. at *15-18. In contrast, the government put
forward two medical studies−the Farez and Confavreux studies−that refute any connection
between the varicella vaccine (Farez study) or the Tdap vaccine (Confavreux and Farez studies)
and multiple sclerosis. Id. at *15. Moreover, while another study−the Zorzon study−finds a
connection between the varicella vaccine and multiple sclerosis, petitioner did not elicit
testimony on this study to support her significant aggravation claim. Id. at *16. And so, the
special master afforded this study no weight.3 Id.
3 Because the Court grants deference to the finder of fact with respect to the probative value of evidence,
the Court will not reconsider the special master’s determination regarding the probative value of the
Zorzon study. Doe, 601 F.3d at 1356.
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Given the lack of evidence in the record to connect any of the relevant vaccines to
multiple sclerosis, the special master reasonably determined that petitioner did not satisfy the
medical theory prong in this case. The Court will not disturb the finding of the special master.4
Because petitioner has not met her burden under the medical theory prong for the
significant aggravation claim, the Court need not address whether she satisfies the other prongs
under Althen and Loving. Veryzer v. Sec'y of Health & Human Servs., 100 Fed. Cl. 344, 355-56
(2011), aff'd sub nom. Veryzer v. United States, 475 F. App'x 765 (Fed. Cir. 2012) (“Absent [a
legally probable medical] theory, a logical sequence of cause and effect showing that receipt of
the . . . vaccine led to petitioner's condition could not be shown. . . . [T]he record did not
establish a plausible medical theory causally connecting the vaccine and the alleged injuries.
Absent such a showing, a temporal association cannot be demonstrated.”). Nonetheless, the
Court agrees with petitioner that the special master erred in analyzing her significant aggravation
claim under the timing and logical sequence prongs. Pet. Mot. at 14-15. And so, the Court
briefly addresses these issues.
2. The Special Master Erred In Analyzing The Timing Prong
With respect to the timing prong, the record evidence shows that the special master erred
in setting a three-day time limit following the vaccinations as the medically acceptable interval
before the onset of Elijah’s symptoms. Dec. at *22-23. Under the timing prong, the petitioner
must demonstrate by a preponderance of the evidence that the injury or significant aggravation
occurred “within a medically acceptable interval following his vaccinations.” Paluck, 786 F.3d
4 It is important also to note that the record is similarly devoid of evidence connecting the relevant
vaccines to ADEM. As discussed above, the Court finds that the special master abused his discretion by
failing to fully consider evidence put forward by petitioner to show that the vaccines caused ADEM. But,
while the record shows that petitioner put forward several medical studies to support her medical theory
that the vaccines caused ADEM, two of those studies do not connect any of the relevant vaccines to
ADEM. See, e.g., Tr. 65:17-66:4 (Johnson article connecting the rabies vaccines to ADEM through
molecular mimicry), 69:2-14 (Tselis article addressing the theories of molecular mimicry and bystander
activation as they relate to ADEM); Exs. 29 at 4, 37 at 6-7. Another medical study−the Hartung article−
states that ADEM is known to follow the DTaP vaccine. Ex. 34 at 2. In addition, a fourth medical
study−the Menge study−states that ADEM can occur after the pertussis vaccination in .9 of 100,000
patients. Tr. 68:5-69:1; Ex. 31 at 2. But, the testimony from petitioner’s own medical expert mitigates
the probative value of this study, because Dr. Mattson testified that the Tdap vaccine probably did not
cause Elijah’s injury. Tr. 60:12-15; 120:5-13. (Dr. Mattson testified that the varicella vaccine was the
most likely cause of Elijah’s injuries because it is a live, attenuated vaccine unlike the Tdap vaccine.)
20

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at 1380. “[T]he proximate temporal relationship prong requires preponderant proof that the
onset of symptoms occurred within a timeframe for which, given the medical understanding of
the disorder’s etiology, it is medically acceptable to infer causation-in-fact.” de Bazan, 539 F.3d
at 1352.
In this case, the special master concluded that “the evidence suggests that an immune-
mediated reaction in a person with an intact central nervous system takes at least five days. [But]
[b]ecause Elijah’s central nervous system already contained some antibodies . . . he [may have]
respond[ed] more rapidly.” Dec. at *22. And so, the special master concluded that “a generous
estimate in [petitioner’s] favor is that the interval might be as few as three days.” Id.
Petitioner, however, presented expert testimony and medical literature to support her
position that a medically appropriate time period for the onset of Elijah’s symptoms is 2 to 21
days after the vaccinations. See Tr. 64:25-65:16 (Scott study finding onset of ADEM symptoms
after the smallpox vaccine within 2 to 18 days); Ex. 35 at 2-3 (Tenenbaum study finding 2 to 28
days is an appropriate interval to expect the onset of symptoms after infection); Ex. 36 at 5
(providing age-based incubation periods for the smallpox vaccine).5 The medical literature put
forward by petitioner provides ample support for the view that the onset of Elijah’s symptoms
could have occurred as early as two days after he received the vaccinations. See Tr. 64:25-65:16;
Ex. 35 at 2-3; Ex. 36 at 5. Given this probative evidence, the special master’s finding of a
medically acceptable interval of no less than three days is not supported by the substantial record
evidence. And so, this finding should be set aside.
The special master’s factual finding that Elijah’s symptoms occurred one day after he
received the vaccinations is similarly contradicted by the record evidence. Dec. at *23. The
record evidence shows that Elijah was sent home by the emergency room medical staff after
being diagnosed with a localized reaction to the vaccines on April 21, 2011. Dec. at *3; Ex. 4 at
3. Rather, it was Elijah’s “stroke-like” symptoms which manifested on April 22, 2011, the
second day after the vaccinations, that prompted his hospitalization and suggest the onset of
more serious neurological symptoms. See Dec. at *5; see generally Ex. 5. And so, the special
5 The special master discredited the Scott article because the data concerned infants, Dec. at *19, and
found the Tenenbaum article’s authority limited because neither expert witness was asked about the
article during his testimony. Id.
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master’s factual determination that the onset of symptoms occurred within one day of the
vaccinations is similarly unsupported by the substantial record evidence and should be set aside.
3. The Special Master Erred In Analyzing The Logical Sequence Prong
Petitioner also correctly argues that the special master erred in his analysis of the logical
sequence prong, by discounting the medical opinion of Elijah’s treating physician, Dr. Mattson,
with regard to whether the vaccines caused a significant aggravation of Elijah’s injury. Pet. Mot.
at 18-21. In his decision, the special master determined that “the factual bases for deferring to
Dr. Mattson simply because he treated Elijah appear to be absent,” because there is no
understanding within the medical community about what causes multiple sclerosis and ADEM.
Dec. at *23. Given the general lack of understanding about the causes of these diseases, the
special master also questioned “how . . . a treating doctor [could] offer a reliable opinion about
whether a vaccination contributed to the disease’s course.” Id. at *24. And so, the special
master concluded that, “[t]he admitted lack of knowledge about the causes of multiple sclerosis
lies at the heart of the finding that Dr. Mattson was not persuasive in opining that vaccinations
can worsen multiple sclerosis.” Id. The Court disagrees.
This Court recognizes that “treating physicians are likely to be in the best position to
determine whether a logical sequence of cause and effect shows that the vaccination was the
reason for the injury.” Andreu, 569 F.3d at 1375 (citing Capizzano, 440 F.3d at 1326) (alteration
in original). In this regard, the record shows Dr. Mattson has detailed, first-hand, knowledge
about Elijah’s medical history and the status of Elijah’s health since the vaccinations. Dec. at
*6-11. The record evidence also shows that, as a professor of neurology at the Indiana
University School of Medicine and the director of the university’s Multiple Sclerosis Center, Dr.
Mattson has extensive expertise and experience in diagnosing and treating multiple sclerosis. Tr.
at 9-12. The fact that there is uncertainty within the medical community about the precise cause
of multiple sclerosis does not alter these salient facts regarding his experience and knowledge of
Elijah’s medical condition. And so, while the special master may “determine whether the
testimony has a reliable basis in the knowledge and experience of the [relevant discipline],”
Terran ex rel. Terran v. Sec’y of Health & Human Servs., 195 F.3d 1302, 1316 (Fed. Cir. 1999)
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(citation omitted) (brackets in original), he should not have discounted the opinion of petitioner’s
medical expert because of an uncertainty about the cause of multiple sclerosis.6
V. CONCLUSION
In sum, petitioner presents a sympathetic and difficult case. There is no dispute that
Elijah has multiple sclerosis. The record evidence also supports a finding that the onset of
Elijah’s multiple sclerosis occurred prior to the time that he received the Tdap, varicella, and
meningococcal vaccines on April 20 2011. And so, petitioner has not proven, by a
preponderance of the evidence, that any of these vaccines were the “but for” cause of Elijah’s
injury.
Nonetheless, there is ample evidence in the record to suggest that Elijah’s medical
condition worsened, significantly, two days after he received these vaccinations. Petitioner
maintains that the vaccines caused this worsening condition and in doing so, she need not prove
her claim to a medical certainty. But petitioner must, nonetheless, show that the vaccines
actually caused the significant aggravation of Elijah’s injury–not just that, accepting the medical
theory as sound, that Elijah’s condition worsened within a medically-acceptable time frame.
W.C., 704 F.3d at 1357. Petitioner has simply not met this burden here. And so, she has not
established an entitlement to any compensation under the Vaccine Act.
For the foregoing reasons, the Court DENIES petitioner’s motion for review and
SUSTAINS the decision of the special master.
The Clerk is directed to enter judgment accordingly.
6 Lastly, while the Court need not reach this issue to resolve this matter, petitioner appears to satisfy the
remaining Loving factors for a significant aggravation claim. See W.C., 704 F.3d at 1357 (quoting
Loving, 86 Fed. Cl. at 144) (holding that to prove a significant aggravation claim a petitioner must show
in addition to the Althen factors, (1) the person’s condition prior to administration of the vaccine, (2) the
person’s current condition (or the condition following the vaccination if that is also pertinent), (3) whether
the person’s current condition constitutes a “significant aggravation” of the person’s condition prior to the
vaccination.) As discussed above, the record evidence shows that Elijah’s medical condition significantly
deteriorated two days after receiving the vaccines. Dec. at *3-4. The record evidence also suggests that
Elijah’s post-vaccination health status was significantly worse than his condition prior to the vaccinations.
See id. In addition, there is no dispute that Elijah’s current diagnosis is multiple sclerosis. Id. at *1. And
so, the evidence suggests that Elijah’s condition worsened significantly two days after he received the
vaccines and in the months following.
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Each party to bear their own costs.
Some of the information contained in this Memorandum Opinion and Order may be
considered privileged, confidential, or sensitive personally-identifiable information that should
be protected from disclosure. Accordingly, this Memorandum Opinion and Order shall be
FILED UNDER SEAL. The parties shall review the Memorandum Opinion and Order to
determine whether, in their view, any information should be redacted prior to publication. The
parties shall also FILE, by Friday, August 28, 2015, a joint status report identifying the
information, if any, that they contend should be redacted, together with an explanation of the
basis for each proposed redaction.
IT IS SO ORDERED.
s/ Lydia Kay Griggsby
LYDIA KAY GRIGGSBY
Judge
24

================================================================================
DOCUMENT 3: USCOURTS-cofc-1_12-vv-00232-2
Date issued/filed: 2015-11-24
Pages: 2
Docket text: PUBLIC DECISION (Originally filed: 10/14/2015) regarding 76 DECISION Fees Stipulation/Proffer. Signed by Special Master Christian J. Moran. (tpj) Copy to parties.
--------------------------------------------------------------------------------
Case 1:12-vv-00232-LKG Document 80 Filed 11/24/15 Page 1 of 2
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
* * * * * * * * * * * * * * * * * * * * *
JACQUELINE S HUNT, *
Legal guardian of a minor child, *
ELIJAH MCLEOD, * No. 12-232V
* Special Master Moran
Petitioner, *
*
v. * Filed: October 14, 2015
*
SECRETARY OF HEALTH * Attorney’s fees and costs; award in
AND HUMAN SERVICES, * the amount to which respondent does
* not object.
Respondent. *
* * * * * * * * * * * * * * * * * * * * *
Daniel H. Pheifer, Esq., Pfeifer Morgan & Stesiak, South Bend, IN, for Petitioner;
Heather L. Pearlman, United States Dep’t of Justice, Washington, DC, for
Respondent.
UNPUBLISHED DECISION ON FEES AND COSTS1
On October 13, 2015, respondent filed a stipulation of fact concerning final
attorneys’ fees and costs in the above-captioned matter. Previously, petitioner
informally submitted a draft application for attorneys’ fees and costs to respondent
for review. Upon review of petitioner’s application, respondent raised objections
to certain items. Based on subsequent discussions, petitioner amended her
application to request $92,500.00 for attorneys’ fees and costs incurred by
petitioner’s counsel, an amount to which respondent does not object. The Court
awards this amount.
On April 10, 2012, petitioner filed a petition for compensation, alleging that
the tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and varicella
1 The E-Government Act of 2002, Pub. L. No. 107-347, 116 Stat. 2899, 2913 (Dec. 17,
2002), requires that the Court post this decision on its website. Pursuant to Vaccine Rule 18(b),
the parties have 14 days to file a motion proposing redaction of medical information or other
information described in 42 U.S.C. § 300aa-12(d)(4). Any redactions ordered by the special
master will appear in the document posted on the website.

Case 1:12-vv-00232-LKG Document 80 Filed 11/24/15 Page 2 of 2
vaccinations, which Elijah received on April 20, 2011, caused development of
acute disseminating encephalomyelitis (ADEM) and a diagnosis of multiple
sclerosis (MS). The information in the record, however, did not show entitlement
to an award under the Program. Decision, issued February 23, 2015, mot. for
review denied (Aug. 13, 2015).
Even though compensation was denied, a petitioner who brings her petition
in good faith and who has a reasonable basis for the petition may be awarded
attorneys’ fees and costs. See 42 U.S.C. § 300aa–15(e)(1). Here, counsel for
petitioner gathered and filed medical records, and obtained reports from experts,
and prepared for and conducted a trial. Thus, because petitioner’s counsel acted in
good faith and because there was a reasonable basis for proceeding, petitioner is
eligible for an award of attorneys’ fees and costs. Respondent does not contend
that petitioner failed to satisfy these criteria.
Ms. Hunt seeks a total of$92,500.00 in attorneys’ fees and costs for her
counsel. Additionally, in compliance with General Order No. 9, petitioner has
filed a statement indicating that while represented by Pfeifer Morgan & Stesiak,
she did not incur costs related to the litigation of this matter. Respondent has no
objection to the amount requested for attorneys’ fees and costs.
After reviewing the request, the Court awards the following:
A lump sum of $92,500.00, in the form of a check made payable to
petitioner and petitioner’s attorney, Daniel H. Pfeifer, of the law firm of
Pfeifer Morgan & Stesiak, for attorneys’ fees and other litigation costs
available under 42 U.S.C. § 300aa-15(e).
The Court thanks the parties for their cooperative efforts in resolving this
matter. The Clerk shall enter judgment accordingly.
Any questions may be directed to my law clerk, Dan Hoffman, at (202) 357-
6360.
IT IS SO ORDERED.
s/Christian J. Moran
Christian J. Moran
Special Master
2