VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_19-vv-00301
Package ID: USCOURTS-cofc-1_19-vv-00301
Petitioner: Ryan Farrell
Filed: 2019-02-26
Decided: 2025-12-10
Vaccine: tetanus-diphtheria-acellular pertussis (Tdap)
Vaccination date: 2017-02-15
Condition: neuromyelitis optica (NMO)
Outcome: compensated
Award amount USD: 210000

AI-assisted case summary:
On February 26, 2019, Ryan Farrell filed a petition alleging that a Tdap vaccine administered on February 15, 2017 caused neuromyelitis optica. He was a 41-year-old electric lineman who received the vaccine after cutting his finger at work.

About three weeks later, after a flu-like illness, Mr. Farrell developed left-eye vision loss, urinary difficulty, and lower-extremity numbness and tingling. Imaging showed optic nerve and spinal cord involvement, and he was diagnosed with likely neuromyelitis optica. His treatment course included steroids and later Rituxan. The case included an expert hearing and extensive competing evidence about immune triggering and relapse/onset timing.

Petitioner relied on treating neurologists including Dr. Salvatore Napoli and Dr. Michael Levy, while respondent relied on experts including Dr. He and Dr. Cohen. The entitlement ruling credited petitioner's theory that Tdap could trigger NMO in this clinical setting. On December 10, 2025, the court awarded $210,000.00 as interim compensation for pain, suffering, and emotional distress through September 1, 2025, with additional future compensation issues left open.

Theory of causation field:
Tdap vaccine February 15, 2017 at age 41 causing NMO. COMPENSATED. Onset about 21 days later with left eye vision loss, urinary difficulty, and lower-extremity numbness/tingling after flu-like illness; optic nerve and spinal cord imaging supported likely NMO; treated with steroids/Rituxan. Petitioner experts/treaters Dr. Salvatore Napoli and Dr. Michael Levy; respondent experts included Dr. He and Dr. Cohen. Entitlement July 29, 2025; interim damages December 10, 2025. Award $210,000.00 interim pain/suffering/emotional distress through September 1, 2025. Petition filed February 26, 2019.

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_19-vv-00301-0
Date issued/filed: 2025-08-20
Pages: 19
Docket text: PUBLIC ORDER/RULING (Originally filed: 07/29/2025) regarding 137 Ruling on Entitlement. Signed by Special Master Christian J. Moran. (jjb) Service on parties made.
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Case 1:19-vv-00301-UNJ Document 141 Filed 08/20/25 Page 1 of 19
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
* * * * * * * * * * * * * * * * * * * * *
RYAN FARRELL, *
* No. 19-301V
* Special Master Christian J. Moran
Petitioner, *
v. *
* Filed: July 29, 2025
SECRETARY OF HEALTH *
AND HUMAN SERVICES, *
*
Respondent. *
* * * * * * * * * * * * * * * * * * * * *
Leah VaSahnja Durant and Glenn MacLeod, Law Offices of Leah V. Durant,
PLLC, Washington, D.C., for Petitioner;
Elizabeth Andary and Emily Hanson, United States Dep’t of Justice, Washington,
D.C., for Respondent.
PUBLISHED RULING FINDING ENTITLEMENT TO COMPENSATION1
Ryan Farrell alleges that a tetanus, diphtheria, and acellular pertussis
(“Tdap”) vaccine caused him to suffer from neuromyelitis optica (“NMO”). Pet.,
filed Feb. 26, 2019. The Secretary disputes Mr. Farrell’s entitlement to
compensation. Both parties have supported their positions with reports and oral
testimony from expert witnesses and argued through memorandum.
1 Because this ruling contains a reasoned explanation for the action taken in this case, it
must be made publicly accessible and will be posted on the United States Court of Federal
Claims’ website, and/or at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in
accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal
Management and Promotion of Electronic Government Services). This means the ruling will be
available to anyone with access to the internet. In accordance with Vaccine Rule 18(b), the
parties have 14 days to identify and move to redact medical or other information, the disclosure
of which would constitute an unwarranted invasion of privacy. Any changes will appear in the
document posted on the website.

Case 1:19-vv-00301-UNJ Document 141 Filed 08/20/25 Page 2 of 19
A review of the evidence and arguments shows that Mr. Farrell is entitled to
compensation. The granting of entitlement is based upon petitioner establishing
with preponderant evidence that the Tdap vaccine caused the NMO. The reasoning
is set forth below.
I. Facts2
Mr. Farrell was born in 1976. He worked as an electric lineman. While
working, he cut his finger. Exhibit 6 at 15-16. As a result, he received the
allegedly causal Tdap vaccine on Wednesday, February 15, 2017. Id.
Due to an “inability to see out of his left eye, difficulty urinating and lower
extremity numbness and tingling in the setting of a recent illness,” Mr. Farrell
sought care at Needham Emergency Room on Wednesday, March 8, 2017. Exhibit
5 at 10. Mr. Farrell informed the medical staff that “over the weekend he
developed what sounds like a flulike illness associated with cough, congestion,
malaise and subjective chills.” Id. Testing for various infectious agents was
negative. Id. at 11, 17. Mr. Farrell was admitted to the hospital. Id. at 5, 8.
While in the hospital, Mr. Farrell underwent two MRIs. An MRI of his head
showed a hyperintense signal in the left optic nerve. Exhibit 3 at 8 (March 9,
2017) and an MRI of his cervical and thoracic spine showed a hyperintense signal
from C5-6 to C7-T1. Id. Based upon these results he was diagnosed with “likely”
“neuromyelitis optica.” Id. This diagnosis was reached despite a lack of
antibodies typically found in NMO patients.
Mr. Farrell was treated with Solu-Medrol for five days and rapidly
improved. He was discharged on March 13, 2017. Exhibit 3 at 8-9.
When out of the hospital, Mr. Farrell saw a neurologist, Jacob Sloane. Dr.
Sloane’s impression was that Mr. Farrell suffered from NMO. Exhibit 3 at 205.
The experts retained for this litigation agree with the diagnosis of NMO.
Dr. Sloane prescribed Rituxan. Rituxan “is an anti-CD19 monoclonal
antibody that targets B cells that have that receptor.” Tr. at 106. This drug “binds
to that receptor on the B cell and creates kind of a cellular toxicity, so that depletes
that B cell.” Id.
2 Relatively few medical records contribute to assessing whether Mr. Farrell is entitled to
compensation. Thus, the recitation of medical records is short. For a longer presentation of
medical records, see Pet'r's Pre-Hearing Br. at 2-6; Resp't's Pre-Hearing Br. at 1-7.
2

Case 1:19-vv-00301-UNJ Document 141 Filed 08/20/25 Page 3 of 19
The course of Mr. Farrell’s NMO over the next few months is generally not
relevant to determining whether the Tdap vaccine caused the NMO. However,
after approximately six months, Mr. Farrell sought a second opinion from a
neurologist, Dr. Salvatore Napoli. Exhibit 4 at 2 (Dec. 19, 2017). Dr. Napoli
obtained a history in which Mr. Farrell got cut, received a tetanus vaccine, and,
three weeks later, developed vision and bladder trouble. Id. Dr. Napoli wrote that
the “implication of this [tetanus] injection is unknown.” Id. at 4. Dr. Napoli
assessed Mr. Farrell as suffering from multiple sclerosis and NMO. He also
prescribed medications. Id.
Dr. Napoli saw Mr. Farrell in December 2017, January 2018, February 2018,
and March 2018. Exhibit 4 at 6-33. On March 8, 2018, Mr. Farrell reported
concerns about his current medication (Cymbalta) and his job. Id. at 34. Dr.
Napoli stated: “I do believe the patient is disabled from all gainful employment. I
also agree that it is more likely than not that the DTaP vaccine may have triggered
the onset of his NMO subtype of demyelinating disease.” Id. at 35.
Dr. Napoli saw Mr. Farrell once more in March 2018 and twice in April
2018. Exhibit 4 at 38-51. Then following these appointments, Mr. Farrell saw
medical professionals less frequently.
Mr. Farrell returned to Dr. Napoli on January 11, 2019. Dr. Napoli again
assessed him as suffering from neuromyelitis optica. Exhibit 44 at 108. Dr.
Napoli said that it was “more probable than not” that Mr. Farrell’s “neuromyelitis
optica and fulminant demyelination was triggered by” his “tetanus vaccination.”
Id.
Dr. Michael Levy saw Mr. Farrell in January 2021, February 2021, June
2021, December 2021, and February 2023. Exhibit 43 at 4, 15, 25, 32; Exhibit 51
at 4. On January 27, 2021, Dr. Levy authorized an ambulatory referral to external
physical therapy for Mr. Farrell from Massachusetts General Hospital Neurology
Virtual Department. Exhibit 43 at 32. On February 23, 2021, Dr. Levy saw Mr.
Farrell virtually for a new patient consult. Id. at 25-27. On June 15, 2021, Dr.
Levy saw Mr. Farrell again and assessed that Mr. Farrell was “a 45[-year-old]
gentlemen with seronegative, monophasic neuromyelitis optica in 2017 following a
vaccination.” Id. at 15. Dr. Levy advised Mr. Farrell to follow-up in about six
months. Id. at 18. On December 7, 2021, Mr. Farrell returned to see Dr. Levy in-
person. Id. at 4, 9. Dr. Levy assessed Mr. Farrell’s diagnosis as “remains
seronegative NMO, likely due to a vaccine injury.” Id. at 5. On February 14,
2023, Mr. Farrell returned to see Dr. Levy and Dr. Anderson. Exhibit 51 at 4. Mr.
Farrell reported at this visit that he weaned off Lyrica and still feels the neuropathy
3

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in his feet. Id. at 1. Dr. Levy and Dr. Anderson reported that Mr. Farrell’s
“neurological function is improving. He is exercising every day and walking. He
eats well and feels healthy. He feels some sensation feelings in his hands that
comes and goes.” Id. Mr. Farrell was advised to follow up in two years. Id. at 4.
A record from January 13, 2021 indicates that Mr. Farrell had an “acute flare
of neuromyelitis optica syndrome.” Exhibit 46 at 23. A more recent record states
that Mr. Farrell has improved and nearly returned to his baseline. Exhibit 51 at 1
(Feb. 14, 2023).
II. Procedural History
Mr. Farrell initiated this case by filing a petition on February 26, 2019. He
periodically submitted medical records.
The Secretary evaluated this material and recommended that compensation
be denied. Resp’t’s Rep., filed pursuant to Vaccine Rule 4, on March 12, 2020. In
the Secretary’s view, Dr. Napoli’s January 28, 2019 letter was insufficient to
establish that the tetanus vaccine caused Mr. Farrell’s NMO. Id. at 9-10.
Mr. Farrell intended to obtain additional reports, either from Dr. Napoli or
from an expert retained for the purpose of this litigation. Accordingly, proposed
instructions were issued on March 24, 2020 and became final on April 16, 2020.
The parties developed evidence from experts over the next few years. For
Mr. Farrell, Dr. Napoli wrote two reports: Exhibit 12, filed October 26, 2020; and
Exhibit 39, filed June 4, 2021. Dr. Levy also wrote two reports: Exhibit 34, filed
May 14, 2021; and Exhibit 41, filed November 23, 2021.3
The Secretary’s pair of experts wrote a total of five reports. Dr. He’s reports
are Exhibit A, filed March 1, 2021; Exhibit E, filed October 5, 2021; and Exhibit
3 Dr. Napoli is a board-certified neurologist, currently working as the medical director
and president of the Neurology Center of New England. Exhibit 52 at 2. Dr. Napoli has written
several publications in the field of neurology and demyelinating diseases, including NMO. Id. at
7.
Dr. Levy is a world-class authority in NMO with over 15 years of clinical and research
expertise in the treatment of NMO. Exhibit 53. Dr. Levy was the director of the NMO Clinic at
the Johns Hopkins Hospital from 2009-2019. Id. at 2. Dr. Levy managed over 425 patients with
NMO while he was at Johns Hopkins. Id. at 32. Dr. Levy currently sees about 160 patients with
NMO. Tr. at 130.
4

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G, filed January 24, 2022. Dr. Cohen’s reports are Exhibits C, filed March 1,
2021; and Exhibit F, filed October 5, 2021.4
After the experts were finished with disclosing their opinions in writing, the
parties were directed to argue their positions through memoranda. Order, issued
March 11, 2022. The parties did. Mr. Farrell submitted his primary brief on June
28, 2022, and his reply brief on January 3, 2023. Between those submissions, the
Secretary offered his assessment through a brief filed on October 12, 2022.
A review of the evidence and arguments suggested that oral testimony was
appropriate, and the parties were instructed to determine mutually convenient dates
for a hearing. Order, issued March 7, 2024. The hearing took place in Boston,
Massachusetts on October 3-4, 2024.
An order to show cause was issued on October 18, 2024 and advised that,
based upon the evidence and arguments, Mr. Farrell was tentatively found to be
entitled to compensation and specified topics that the parties should address in
their post-hearing briefs. Respondent filed his post-hearing brief on February 3,
2025. Petitioner filed his response to respondent’s brief on April 18, 2025.
Respondent did not submit a reply.
The case is ready for adjudication.
III. Standards for Adjudication
A petitioner is required to establish his case 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
4 Dr. He is a professor of immunology in the department of immunology at Duke
University Medical Center. Exhibit A at 1. Dr. He’s research areas include human immune
responses to viral infections, including influenza, HIV, HBV, and HCV. Id. Dr. He has served
as a review expert for the NIH Study Section Cellular and Molecular Immunology-B and an ad
hoc member for the NIH Biodefense Study Section. Id. at 1-2.
Dr. Cohen holds certifications in clinical neurophysiology and neuromuscular disease.
Exhibit C at 1. Dr. Cohen is a professor and chair of the department of neurology at the Geisel
School of Medicine and the Dartmouth Hitchcock Medical Center. Id. Dr. Cohen had a clinical
practice for 39 years, diagnosing and treating an average of 10 patients a year for MS and about
two to three patients a year for NMO. Id.
5

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Health & Hum. 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 &
Hum. 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 & Hum. 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 & Hum. Servs., 219 F.3d 1357
(Fed. Cir. 2000); Hodges v. Sec’y of Health & Hum. 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).
IV. Causation
Because the Vaccine Injury Table does not associate the Tdap vaccine with
NMO, Mr. Farrell must pursue a claim that the Tdap vaccine was the cause-in-fact
of the NMO. See Pet’r’s Pre-Hearing Br. at 7-8. For causation-in-fact claims, a
petitioner bears a burden “to show by preponderant evidence that the vaccination
brought about [the vaccinee’s] injury by providing: (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 & Hum. Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005).
A. Althen Prong One – Medical Theory
Mr. Farrell’s brief discussed a medical theory of molecular mimicry to
explain how the Tdap vaccine can cause NMO. See Pet’r’s Pre-Hearing Br. at 8-
11. In support of his claim, Mr. Farrell relies upon an epidemiologic study and
opinions from two experts specializing in diagnosing and treating NMO, Dr.
Napoli and Dr. Levy.
1. Epidemiologic Study
Mr. Farrell meets his burden of proof largely due to a supporting
epidemiologic study. For a lengthy discussion of the value of epidemiologic
studies in the Vaccine Program, see Tullio v. Sec’y of Health & Hum. Servs., No.
15-51V, 2019 WL 7580149, at *5-8 (Fed. Cl. Spec. Mstr. Dec. 19, 2019), mot. for
rev. denied, 149 Fed. Cl. 448, 475 (2020). Epidemiology is concerned with
6

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whether a causal relationship exists between an agent and a disease.5 The first
question epidemiology addresses is whether an association exists between
exposure to the agent and disease. GREEN, supra note 5, at 566. “An association
between exposure to an agent and disease exists when they occur more frequently
than one would expect by chance.” Id.
In support of his claim, Mr. Farrell advanced medical articles, including an
epidemiological study conducted by Dr. Levy and his colleagues in 2018. Exhibit
37 (Mealy).6 The Mealy study is a multi-center retrospective analysis of patients
with NMOSD for whom immunization history and clinical records from disease
onset were available. Id. at 78.
The study identified that
the concern with vaccines involves the potential risk of non-specific
immune activation in patients with immune-mediated diseases. In this
study, we investigated the association of a relapse occurring within
30, 60, and 90 days of a vaccination and compared it with the
association of a relapse occurring within randomly selected dates.
The goal was to determine if vaccines increase the risk of an NMOSD
relapse.
Id. at 79 (internal citation omitted). Relapses were defined “across all centers as a
new or worsening acute neurologic symptom lasting at least 24 [hours], associated
with a change in exam localizing to the CNS and not explainable by fever,
infection or metabolic condition.” Id.
Ninety patients that met the 2015 diagnostic criteria for NMOSD received a
total of 211 vaccinations and experienced 340 relapses. Id. The study compared
the likelihood of a relapse occurring within 30, 60, and 90 days of a vaccine with
the likelihood of a relapse occurring within each time point of a randomly
generated date. Id. The study found that the “rate of vaccine-associated relapses
within 30, 60, and 90 days was significantly higher than the likelihood of a relapse
spontaneously occurring within each of the given time frames (p = 0.034, 0.01,
5 Michael D. Green, et al., Reference Guide on Epidemiology, in REFERENCE MANUAL ON
SCIENTIFIC EVIDENCE 566 (3d ed. 2011).
6 Maureen A. Mealy, et al., Vaccines and the association with relapses in patients with
neuromyelitis optica spectrum disorder, 23 MULTIPLE SCLEROSIS & RELATED DISORDERS 78-82
(2018), filed as Exhibit 37.
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0.016, respectively) among patients who were not on preventative immunotherapy
only.” Id. at 78. The study suggested that “there may be a risk of vaccination-
associated relapses among untreated neuromyelitis optica spectrum disorder
patients, however immunosuppressive therapy at time of vaccine may abort the
risk.” Id.
Ninety-five percent of relapses documented in the study were characterized
as myelitis and/or optic neuritis. Id. at 79. Additionally, it was noted that “Five of
the attacks were at the disease onset and eleven occurred later in the disease
course.” Id. Two of the five attacks that were at the disease onset were associated
with the Td and Tdap vaccines. Id. at 80.
In analyzing the results, vaccines were associated with relapses in patients
with NMOSD who were not on preventative immunotherapy, with the highest
association occurring during the first 30 days after a vaccine. Id. at 80. The
authors acknowledged that
While the number of patients available in our cohort of a rare disease
does not enable us to make any conclusions about specific vaccines,
the data in MS largely mirror that in NMOSD, such that, overall, there
appears to be no increased risk of relapses associated with
vaccinations. However, the MS literature does not separately analyze
the impact that disease modifying therapy may have on this
association. Interestingly, most studies examining the relationship
between MS onset and tetanus vaccination administration suggest that
the vaccine may play a preventative role in MS development, and
while less evidence supports this, some data suggest the same of the
diphtheria vaccine. This contrasts with our findings of a
disproportionate relationship between the tetanus + / - diphtheria
vaccine and a subsequent relapse. Given the low number of patients
receiving this vaccine in our cohort, more investigation is warranted,
but this may be a result of the differing immunopathogenic
mechanisms that distinguish MS from NMOSD.
Id. at 80-81 (internal citation omitted). The number of observed relapses that
occurred within 30 days of a vaccine in the untreated NMOSD study population
was outside the range of expectation. Id. at 81.
The authors also acknowledged that the study was limited by the inherent
biases that exist in retrospective data analyses and thus, lacked rigorous controls.
“Selection bias was minimized through the wide inclusion of any patients for
8

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whom detailed vaccinations and clinical records were available, regardless of
frequency of follow-up at each participating center.” Id. at 82.
At the hearing, Dr. Levy explained the significance of this article in
supporting a medical theory causally connecting the Tdap vaccine and NMO. In
Dr. Levy’s words,
the significance [of this article] is that we’d heard from a lot of our
patients that they believe that their disease was linked to vaccines. So
what we did was we said, okay, we’ll take your event and we’ll line
up all of your relapses with all of your other vaccines and see if there
is a random pattern of vaccines associated with relapses or if there is a
more specific pattern of potential causation. And what we found is
that statistically there were more events of relapses occurring after --
immediately after, 30 days, 60 days, or 90 days after a vaccine then
would be accounted for by just random activity. So statistically, it
does seem to be linked.
Tr. at 147-48. Even though the article title uses the word “relapses,” Dr. Levy
explained that five of the patients in the study were “new onset” of the disease. Tr.
at 150, 153.
The Secretary disputed that the Mealy article constituted epidemiological
evidence that supported Mr. Farrell’s theory. The Secretary argued, even if the
Mealy article constituted epidemiological evidence, that its weight is undermined
because it contains a methodological flaw in that the subject population was
selected based on a pre-existing suspicion that the subjects had suffered vaccine-
related relapses. Resp’t’s Post-Hearing Br. at 16. The Secretary argued that the
Mealy article, while it “may be somewhat probative with regard to vaccines
generally as triggers for relapse in cases of NMO, it does not provide
epidemiological support for petitioner’s contention that the Tdap vaccine
specifically can cause NMO.” Id. at 17 (emphasis in original). The Secretary
argued that this article merits little weight in determining whether Mr. Farrell has
met the required standards under prong one.
However, when Dr. Levy was questioned about the title of the study
referring to only relapses in the Mealy article, he testified that was “because we use
‘relapse’ too loosely.” Tr. at 177. Additionally, Dr. Levy testified that “But
maybe even in my notes, I refer to Mr. Farrell’s attack as a relapse. I might have.
It’s kind of a slip of the tongue, but it’s not – it’s not accurate to say it that way. . . .
We should have been more correct in the title.” Id. Dr. Levy’s testimony and the
9

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Mealy article persuasively explain how the theory of molecular mimicry explain
how the Tdap vaccine can cause NMO.
The presence of an epidemiologic study finding that vaccinations are
associated with an increased incidence of a disease is strong evidence favoring an
award of compensation. See In re Swine Flu Immunization Prods. Liab. Litig., 508
F. Supp. 897, 907 (D. Colo. 1981) (“Where, as here, the exact organic cause of a
disease cannot be scientifically isolated, epidemiologic data becomes highly
persuasive”), aff'd sub nom. Lima v. United States, 708 F.2d 502 (10th Cir. 1983);
In re Agent Orange Prod. Liab. Litig., 611 F. Supp. 1223, 1239 (E.D.N.Y. 1985)
(stating that in mass tort cases, “epidemiologic studies on causation assume a role
of critical importance”), aff'd sub nom. In re Agent Orange Prod. Liab. Litig. MDL
No. 381, 818 F.2d 187 (2d Cir. 1987). Epidemiologic studies often fail to detect an
increased incidence, and special masters may consider the lack of a positive
finding in an epidemiologic study in denying compensation. See Tullio. When the
opposite occurs, a special master should also consider this evidence to determine
where the weight of the evidence preponderates. Andreu v. Sec'y of Health &
Hum. Servs., 569 F.3d 1367, 1380 (Fed. Cir. 2009) (“Medical literature and
epidemiological evidence must be viewed, however, not through the lens of the
laboratorian, but instead from the vantage point of the Vaccine Act's preponderant
evidence standard.”). Here, the Mealy epidemiological study, while not required to
support a claim, provides ample support for a reputable theory establishing how a
Tdap vaccine can cause NMO.
2. Expert Opinions on Molecular Mimicry
Dr. Napoli and Dr. Levy opined that molecular mimicry is a mechanism by
which tetanus vaccines can cause NMO. Dr. Napoli and Dr. Levy provided
persuasive evidence explaining the medical mechanism that is believed to cause
NMO. Dr. Napoli explained that
Vaccinations are composed of organic compounds of viral or bacterial
origin. These are meant to stimulate an immune response when
injected. If the antigen present on the vaccine shares any homologies
with host antigen, then immune response will be directed at both the
injected antigens and host antigen leading to an autoimmune response.
This is known as molecular mimicry which is a well-known response
in immunology (Lahesmaa et al. Clin Exp Immunol 1991 86(3): 399-
404). As previously noted, AQP-4 has been identified as the protein
present in astrocytes which is the target for specific NMO antibodies.
Molecular mimicry has been linked to the development of NMO due
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to the similarity in epitopes of AQP-4 water channels and antigens,
examples such as Hep B vaccination.
Exhibit 12 at 6. Dr. Levy opined that
The specific components of the Tdap vaccine are used in mouse
models to trigger immune mediated neurological injury, especially the
pertussis toxin (the “p” of the Tdap vaccine), which is hypothesized to
transiently break down the blood brain barrier and permit the immune
system to invade the nervous system. Molecular mimicry has been
demonstrated in mouse models of neuromyelitis optica where
immunization with the ABC water transporter of the Campylobacter
bacterium that shares homology with the aquaporin-4 can recapitulate
the human disease phenotype.
Ex. 34 at 3.
The Secretary argued that Mr. Farrell’s theory is not sufficiently detailed or
specific to meet the requirements of prong one of Althen. In contesting Mr.
Farrell’s claim, the Secretary submitted reports from Dr. He and Dr. Cohen.
Exhibit A, E, G; Exhibit C, F.
The Secretary also advanced testimony and articles arguing that recent
evidence undermines the theory of molecular mimicry. The Secretary’s expert, Dr.
He, opined that evidence of cross-reactivity alone does not support the conclusion
that the Tdap vaccine can cause NMO because cross-reactivity happens constantly.
Exhibit E at 6. Dr. He also testified that homology is not enough to establish
molecular mimicry. Tr. at 276-78. Dr. He submitted three articles to support his
opinion. Exhibit A, Tab 11 (Kanduc);7 Exhibit A, Tab 12 (Trost);8 Exhibit A, Tab
13 (Kusalik).9 These articles focus largely on amino acid sequences through the
human proteome. The Secretary contended that evidence “of sequence homology
and cross-reactivity are components of molecular mimicry, but do not demonstrate
that a pathological outcome is likely, or even possible.” Resp’t’s Post-Hearing Br.
7 Darja Kanduc, et al., Massive peptide sharing between viral and human proteomes, 29
PEPTIDES 1755-66, 1755 (2008), filed as Exhibit A, Tab 11.
8 Brett Trost, et al., Bacterial peptides are intensively present throughout the human
proteome, 1 SELF/NON-SELF 71-74, 71 (2010), filed as Exhibit A, Tab 12.
9 Anthony Kusalik, et al., Widespread and ample peptide overlapping between HCV and
Homo sapiens proteomes, 28 PEPTIDES 1260-67, 1260 (2007), filed as Exhibit A, Tab 13.
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at 20. However, Mr. Farrell’s experts and articles support preponderantly that
molecular mimicry is a reliable theory, even if it is not accepted at a level of
scientific certainty.
Dr. Levy disagreed with Dr. He and testified that molecular mimicry is
the best mechanism we have. We don’t really have another
good explanation for why this would happen, but I should say
it’s the basis of almost all of our neuroimmunological
mechanisms. There has to be some reason the immune system
makes this mistake. So molecular mimicry is the best
explanation for why the immune system would make this
mistake.
Tr. at 155. Dr. Levy also testified that he thinks molecular mimicry is still “a very
valid general mechanism.” Tr. at 157.
3. Assessment
To the extent that the parties disagree, Mr. Farrell has provided sufficient,
preponderant evidence to demonstrate a reputable medical theory that supports that
Tdap vaccination can cause NMO through the mechanism of molecular mimicry.
The Mealy epidemiological study, combined with the expert reports and
testimonies of Mr. Farrell’s treating doctors tilts the evidence in Mr. Farrell’s
favor, helping him establish his claim preponderantly. Unlike in some other cases
that may rely on expert opinions and case studies to try and establish their claim to
entitlement, the addition of an epidemiological study provides the level of
preponderant support to demonstrate how molecular mimicry is a viable
mechanism to establish how a Tdap vaccine can cause NMO. While
epidemiological studies are not necessary to prove a successful claim in the
Vaccine Program, here, this study provides enough support beyond vaguely raising
molecular mimicry as a possible biological mechanism as to how a vaccine can
cause a disease.
Under the circumstances in which an epidemiologic study supports a finding
that a vaccine can cause an injury and in which the Secretary has not meaningfully
contested a proposed theory, an in-depth exploration of the theory is not required.
The epidemiologic study persuasively shows that the Tdap vaccine can cause
NMO. How that occurs---whether by molecular mimicry or some other means---is
much less important than the showing that it does occur. See Lane v. Sec'y of
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Health & Hum. Servs., No. 19-501V, 2024 WL 3584871, at *5 (Fed. Cl. Spec.
Mstr. June 7, 2024).
For these reasons, Mr. Farrell has met his burden of proof regarding prong
one. Thus, the remaining Althen elements are considered.
B. Althen Prong Three – Timing
Althen’s third prong requires “a showing of a proximate temporal
relationship between vaccination and injury.” 418 F.3d at 1278. The timing prong
actually contains two parts. A petitioner must show the “timeframe for which it is
medically acceptable to infer causation” and the onset of the disease occurred in
this period. Shapiro v. Secʼy of Health & Hum. 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 F. App’x 952 (Fed. Cir. 2013).
The medically acceptable timeframe depends, at least in part, on the theory
being offered. Langland v. Sec’y of Health & Hum. Servs., 109 Fed. Cl. 421, 443
(2013).
Mr. Farrell argued that he has produced evidence showing a proximate
temporal relationship between vaccination and onset of his NMO symptoms. Mr.
Farrell presented opinions from Dr. Napoli and Dr. Levy regarding a timeframe
from which an inference of causation is appropriate. Dr. Napoli opined that an
onset of NMO symptoms occurring within five weeks and up to 10 weeks after
vaccination is an appropriate timeframe for causation. Exhibit 12 at 7. Dr. Levy
opined that “vaccine associated attacks” such as NMO “most often occur within
the first 30 days from the jab, but can rarely occur 60 or even up to 90 days later in
rare cases.” Exhibit 34 at 2.
Dr. Napoli’s and Dr. Levy’s opinion that the onset of NMO 21 days post-
vaccination is also supported by the Mealy article. Vaccine associated relapses
were defined as those relapses that occurred “within 30, 60 or 90 days following an
immunization.” Exhibit 37 (Mealy) at 79.
For the second part of Althen prong three, Mr. Farrell argued that his NMO
symptoms arose within the medically acceptable timeframe proposed by Dr.
Napoli and Dr. Levy. Pet’r’s Post-Hearing Br. at 51. Dr. Napoli opined that “to a
reasonable degree of medical certainty that the vaccination on February 15, 2017,
more probably than not, caused and triggered symptoms that Mr. Farrell
experienced after, with subsequent visit to Beth Israel Medical Center on March 8,
2017.” Exhibit 12 at 7. Dr. Levy agreed with Dr. Napoli that “the chronology
13

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between the time of the vaccination and the onset of [NMO] symptoms 3 weeks
later” was “well within the accepted time period for a vaccine induced neuro
immunological injury.” Exhibit 34 at 4.
Dr. Napoli’s and Dr. Levy’s opinion that the onset of NMO 21 days post-
vaccination is also supported by the Mealy article. Vaccine associated relapses
were defined as those relapses that occurred “within 30, 60 or 90 days following an
immunization.” Exhibit 37 (Mealy) at 79.
The 30-day time point was chosen as the primary analysis based on a
large study that suggested there was no increased association of any
CNS demyelination beyond 30 days from time of vaccine
administration (Langer-Gould et al., 2014), and the analysis was
extended in this study to 60- and 90-day time points based on case
reports of temporality of vaccination to relapse in NMOSD beyond 30
days (Menge et al., 2012).
Id.
The Secretary disputed that Mr. Farrell provided any evidence to support
that the Tdap vaccine can cause NMO in any timeframe, which makes it
impossible to affix a time period in which it would be acceptable to infer vaccine
causation. The Secretary argued that Dr. Napoli and Dr. Levy acknowledged in
their testimony that their primary support for the causal theory is based simply on
timing, which is insufficient to show a causal link between the Tdap vaccination
and Mr. Farrell’s NMO. Resp’t’s Post-Hearing Br. at 30 citing Tr. at 26, 202.
However, Mr. Farrell argued that the Secretary’s expert, Dr. He, conceded
that the appropriate timing is met. Dr. He opined that
Indeed, Mr. Farrell’s vaccination on February 15, 2017, and his
symptoms after vaccination with subsequent visits at the Beth Israel
Medical Center on March 8, 2017, are consistent with the temporal
relationship between the receipt of Tdap vaccination and his NMO
disease development (meaning that the time frame between the receipt
of the vaccination and the development of NMO symptoms is
medically possible).
Exhibit A at 7; Tr. at 326.
Here, Mr. Farrell has met the requirements of prong three of Althen with
preponderant evidence. Mr. Farrell has established an acceptable medical theory
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that NMO symptoms can develop within 30 days post-vaccination and that his
symptoms did occur within 21 days post-vaccination.
C. Althen Prong Two – Logical Sequence
The remaining Althen prong requires a preponderant presentation of “a
logical sequence of cause and effect showing that the vaccination was the reason
for the injury.” Althen, 418 F.3d at 1278. With respect to this prong, the Federal
Circuit has instructed special masters to consider carefully the views of a treating
doctor. Capizzano v. Sec’y of Health & Hum. Servs., 440 F.3d 1317, 1326 (Fed.
Cir. 2006) (“medical records and medical opinion testimony are favored in vaccine
cases, as 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’”) (quoting Althen, 418 F.3d at 1280).
Recommendations to avoid certain vaccines have been credited and have not
been credited as indications of a causal role for a vaccine. Compare Paterek v.
Sec’y of Health & Hum. Servs., 527 F. App’x 875, 884 (Fed. Cir. 2013) (stating
given the testimony of a treating doctor, “the decision to withhold future
administration of the pertussis vaccine provides little probative evidence of
causation”); Gramza v. Sec’y of Health & Hum. Servs., 139 Fed. Cl. 309, 335-36
(2018) (ruling that the special master was not arbitrary in refraining from giving
decisive weight to a note from a treating doctor advising “no future vaccination”
when the treater wrote the note three years after the incident); and Bangerter v.
Sec’y of Health & Hum. Servs., No. 14-1187V, 2022 WL 439535, at *29 (Fed. Cl.
Spec. Mstr. Jan. 18, 2022) (although a recommendation to avoid future
vaccinations has some value, this evidence does not carry petitioner’s burden on
prong two when petitioner failed to meet prongs one and three) With Andreu v.
Sec’y of Health & Hum. Servs., 569 F.3d 1367, 1377 (Fed. Cir. 2008) (the opinion
of a treating doctor to withhold future vaccines can be quite probative); and
Robinson v. Sec’y of Health & Hum. Servs., No. 14-952V, 2021 WL 2371721,
*1376-77 (Fed. Cl. Spec. Mstr. Apr. 12, 2021) (evidence that treating doctor
withheld vaccines helps support prong two).
Mr. Farrell argued that he has produced evidence of a logical sequence of
cause and effect showing that the Tdap vaccination was the reason for Mr. Farrell’s
NMO. Pet’r’s Post-Hearing Br. at 33-50. Mr. Farrell asserted that Dr. Napoli’s
credible testimony reinforced Mr. Farrell’s claim “that the Tdap vaccine was a
trigger and causative of the patient’s subsequent NMO.” Tr. at 33. Importantly,
Dr. Napoli, as both an expert and treating physician, is afforded considerable
weight when assessing a logical sequence of cause and effect. Dr. Napoli also
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opined that it was “more probable than not that the [Tdap] vaccine may have
triggered the onset of [Mr. Farrell’s] NMO subtype of demyelinating disease.”
Exhibit 4 at 35.
Mr. Farrell argued that Dr. Levy’s opinion on vaccine causation is based
upon more than simply temporal relation and lack of alternative causes. Mr.
Farrell asserted that Dr. Levy’s opinion is based on “solid scientific evidence,
including numerous published peer reviewed scientific research and studies,
including of his own epidemiologic studies (Mealy), as well as the specific facts
and circumstances of Mr. Farrell’s illness.” Pet’r’s Post-Hearing Br. at 38
(emphasis in original). Dr. Levy opined that “The cause of [Mr. Farrell’s NMO]
attack is most likely related to a vaccine Mr. Farrell received just prior to the attack
on February 17, 2017.” Exhibit 34 at 2. Dr. Levy explained that Mr. Farrell’s
“attack occurred starting 14 days after immunization. There is nothing else in Mr.
Farrell’s prior history that could confound the chronological link such as the use of
immunosuppressive medication or known autoimmune disease.” Id.
Dr. Levy opined that
In Mr. Farrell’s case, an aquaporin-4 antibody was not present at the
time of the time suggesting that a different immunological antigen
was the target in his case. Since March 2017, a new neurological
target called myelin oligodendrocyte glycoprotein (MOG) was found
to be to be present in up to 40% of patients with neuromyelitis optica
who test negative for the aquaporin-4 antibody. At the time of Mr.
Farrell’s attack, the MOG antibody test was not available. Notably,
this antibody does not remain in circulation in the majority of patients
beyond 6-12 months after an attack. Mr. Farrell tested negative for the
MOG antibody when it became commercially available but that does
not necessarily mean MOG was not the target of his attack. In my lab,
we continue to search for additional neurological antigens of aberrant
immune attacks.
Id. at 3-4. Dr. Napoli testified that in his own practice, with a patient like Mr.
Farrell, he “would not recommend [Mr. Farrell] get the Tdap vaccine, and I suspect
95 percent of providers would agree with that.” Tr. at 41. When asked whether he
would advise Mr. Farrell to get a Tdap vaccine, Dr. Napoli stated that he would
advise Mr. Farrell not to get “this specific vaccine, the Tdap.” Id. at 95. When Dr.
Napoli was asked how he would advise Mr. Farrell if Mr. Farrell had stepped on a
rusty nail, he testified that he would talk to Mr. Farrell’s team of doctors and
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specialists to weigh the risks and benefits of vaccination, if he was on an
immunosuppressant treatment. Id.
So there may be the possibility that a team approach might say, hey,
maybe you should get it, because the risk of having tetanus might be
higher than NMO again, but we’re not sure what that risk is. And,
ultimately, he’d have to make the decision, you know, if he wanted to
do it. So in that scenario, it’s a great example of – how we approach
in the offices that scenario, probably work as a team, bring in other
providers involved in coming up with the benefits and also what could
happen.
Id. at 96. Similarly, Dr. Levy testified that he usually advises his patients “to
receive a vaccine because all of my NMO patients are treated, and we know that
treated patients who take vaccines have better outcomes.” Id. at 189.
Dr. Levy, like Dr. Napoli, is one of Mr. Farrell’s treating physicians and Mr.
Farrell argues that Dr. Levy’s testimony is entitled to significant weight. Pet’r’s
Post-Hearing Br. at 37.
The Secretary argued that Mr. Farrell’s causation theory is insufficient to
prove a logical sequence of cause and effect. Resp’t’s Post-Hearing Br. at 24-26.
The Secretary points to the progression of the strength of Dr. Napoli’s opinion
regarding causation throughout the course of treatment. The Secretary asserted
that because Dr. Napoli’s opinion progressed from “[t]he implication of [the Tdap]
injection is unknown,” Exhibit 4 (December 19, 2017) at 2, to a few months later
stating that it was “more probable than not that [the Tdap] vaccine may have
triggered the onset of [Mr. Farrell’s] NMO subtype of demyelinating disease,” Id.
(March 8, 2018) at 35, then to it was “more probable than not, that [Mr. Farrell’s]
diagnosis [w]as related to the Tdap vaccination,” Exhibit 7 (September 6, 2018) at
1, and finally escalating his opinion to being “more likely than not triggered” by
the February 2017 Tdap vaccination, Exhibit 9 (January 28, 2019) at 2, weakens
the credibility of his opinion because it was written just under one month before
Mr. Farrell filed his petition for vaccine compensation. Resp’t’s Post-Hearing Br.
at 24-25.
The Secretary argued that Dr. Napoli’s opinion did not provide anything
other than temporal proximity to support his revised opinion. The Secretary
maintained that Dr. Napoli’s opinion of vaccine causation should be assigned little
weight. Resp’t’s Post-Hearing Br. at 25.
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Similarly, the Secretary contended that Dr. Levy’s opinion that Mr. Farrell’s
NMO was caused by the Tdap vaccine relies solely on the proximate temporal
relationship and lack of other explanations is not sufficient to demonstrate
causation. Resp’t’s Post-Hearing Br. at 26.
The Secretary next argued that there were alternative causes reasonably
raised in the record, even if the Secretary did not pursue a formal alternative cause
argument. Id. The Secretary pointed to medical records that undercut Mr.
Farrell’s claim of vaccine causation, specifically symptoms of a viral illness prior
to his neurological disease onset, even if the specific infectious agent behind Mr.
Farrell’s symptoms was not identified. Testimony from Dr. Cohen and Dr. He
underscored the Secretary’s argument and opined that a wild pathogen causes a
“much stronger” immunologic response than a Tdap vaccine. Tr. 290-92. The
Secretary disputed whether Mr. Farrell has met his burden under prong two of
Althen. Resp’t’s Post-Hearing Br. at 23-29.
Mr. Farrell responded to Dr. He’s assertion that a flu-like illness was far
more likely to have caused a “potent immunological stimulus,” triggering Mr.
Farrell’s NMO as being nothing more than conjecture. See Exhibit G at 3; Pet’r’s
Post-Hearing Br. at 39. Mr. Farrell argued that he was never diagnosed nor treated
for an infectious illness prior to the onset of his NMO. Id. Mr. Farrell’s NMO
started on March 3, 2017 or March 4, 2017. On March 8, 2017, Mr. Farrell’s
doctor noted that he had a flu-like illness one week prior, placing the flu-like
symptoms on March 1, 2017 at the earliest. Mr. Farrell argued that even if he had
a “viral illness” on March 1, 2017, that would be too soon to have caused Mr.
Farrell’s NMO two days later. See Exhibit 3 at 31; Tr. at 124-25, 181-82.
Additionally, Mr. Farrell’s experts contended that all Mr. Farrell’s reported non-
specific symptoms of a viral illness can also be associated with NMO. Tr. at 51,
161-63.
Based on the record as a whole, it appears more likely than not that Mr.
Farrell has established a logical sequence of cause and effect, supported by his
treating doctors, that the Tdap vaccine caused his NMO. As such, Mr. Farrell has
met his burden under prong two of Althen.
D. Summary regarding Causation
To establish the vaccine was the cause-in-fact of an injury, a petitioner must
establish three elements. The undersigned has reviewed all expert reports, articles,
witness testimony, and briefs submitted by the parties. In this case, the evidence
preponderates in Mr. Farrell’s favor. Mr. Farrell provided persuasive expert
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opinions, supported by reliable medical articles, to meet his burden on all three
elements. The Secretary has not met his burden regarding alternative causation.
V. Conclusion
As evident in medical records and consistent with Mr. Farrell’s experts and
treating doctors, Mr. Farrell has preponderantly established that he is entitled to
compensation. A separate order regarding damages will issue.
IT IS SO ORDERED.
s/Christian J. Moran
Christian J. Moran
Special Master
19

================================================================================
DOCUMENT 2: USCOURTS-cofc-1_19-vv-00301-1
Date issued/filed: 2025-12-10
Pages: 15
Docket text: PUBLIC DECISION (Originally filed: 10/28/2025) regarding 154 DECISION of Special Master. Signed by Special Master Christian J. Moran. (jjb) Service on parties made.
--------------------------------------------------------------------------------
Case 1:19-vv-00301-UNJ Document 165 Filed 12/10/25 Page 1 of 15
CORRECTED1
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
* * * * * * * * * * * * * * * * * * * * *
RYAN FARRELL, *
* No. 19-301V
* Special Master Christian J. Moran
Petitioner, *
v. *
* Filed: October 28, 2025
SECRETARY OF HEALTH *
AND HUMAN SERVICES, *
*
Respondent. *
* * * * * * * * * * * * * * * * * * * * *
Leah VaSahnja Durant and Glenn MacLeod, Law Offices of Leah V. Durant, PLLC, Washington,
D.C., for Petitioner;
Elizabeth Andary and Emily Hanson, United States Dep’t of Justice, Washington, D.C., for
Respondent.
PUBLISHED DECISION AWARDING INTERIM COMPENSATION2
Ryan Farrell established that a tetanus, diphtheria, and acellular pertussis (“Tdap”)
vaccine caused him to suffer from neuromyelitis optica (“NMO”). Entitlement Ruling, issued
July 29, 2025, 2025 WL 2409187. He has sought an interim award of compensation for his pain,
suffering, and emotional distress. The Secretary opposes an interim award, primarily upon legal
(as opposed to factual) grounds. For the reasons explained below, Mr. Farrell is awarded
$210,000.00.
1 This decision was corrected to include payment disbursement information.
2 Because this decision contains a reasoned explanation for the action taken in this case, it
must be made publicly accessible and will be posted on the United States Court of Federal
Claims’ website, and/or at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in
accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal
Management and Promotion of Electronic Government Services). This means the decision will
be available to anyone with access to the internet. In accordance with Vaccine Rule 18(b), the
parties have 14 days to identify and move to redact medical or other information, the disclosure
of which would constitute an unwarranted invasion of privacy. Any changes will appear in the
document posted on the website.

Case 1:19-vv-00301-UNJ Document 165 Filed 12/10/25 Page 2 of 15
I. Facts3
Sources of information about Mr. Farrell’s condition come from three sources: medical
records, his affidavits, and oral testimony from the experts retained.
A. Medical Records
Mr. Farrell was born in 1976. He worked as an electric lineman. While working, he cut
his finger. Exhibit 6 at 15-16. As a result, he received the causal Tdap vaccine on Wednesday,
February 15, 2017. Id.
Due to an “inability to see out of his left eye, difficulty urinating and lower extremity
numbness and tingling in the setting of a recent illness,” Mr. Farrell sought care at Needham
Emergency Room on Wednesday, March 8, 2017. Exhibit 5 at 10. Mr. Farrell informed the
medical staff that “over the weekend he developed what sounds like a flulike illness associated
with cough, congestion, malaise and subjective chills.” Id. Testing for various infectious agents
was negative. Id. at 11, 17. Mr. Farrell was transferred to a hospital in Boston. Id. at 11.
In the emergency room at Beth Israel Deaconess Hospital, Mr. Farrell rated his pain as a
six out of ten. Exhibit 3 at 27. Mr. Farrell also reported “pain with movement” during his initial
consultation with a neurologist in the hospital. Id. at 48. Other problems included urine and
stool retention. Based upon this presentation, the neurologist was concerned about various
demyelinating conditions and admitted Mr. Farrell to the hospital. Id.
While in the hospital, Mr. Farrell underwent two MRIs. An MRI of his head showed a
hyperintense signal in the left optic nerve. Exhibit 3 at 8 (March 9, 2017). An MRI of his
cervical and thoracic spine also showed a hyperintense signal from C5-6 to C7-T1. Id. Based
upon these results he was diagnosed with “likely” “neuromyelitis optica.” Id. This diagnosis
was reached despite a lack of antibodies typically found in NMO patients.
The initial nurse’s assessment memorialized that Mr. Farrell complained of chronic and
intermittent pain in his lower back at baselines. Exhibit 3 at 38. Mr. Farrell received
occupational therapy and physical therapy. See id. at 54-58 (initial occupational therapy
evaluation) and 65-68 (initial physical therapy evaluation). Mr. Farrell was treated with Solu-
Medrol for five days and rapidly improved.4 He was discharged on March 13, 2017. Exhibit 3
at 8-9. At the time of discharge, Mr. Farrell could walk independently. Id. at 7.
When out of the hospital, Mr. Farrell saw a neurologist, Jacob Sloane. Dr. Sloane’s
impression was that Mr. Farrell suffered from NMO. Exhibit 3 at 205 (Mar. 16, 2017). The
3 A portion of the evidence summarized here repeats from the July 29, 2025 Entitlement
ruling. However, this decision emphasizes the evidence showing Mr. Farrell’s pain, suffering,
and emotional distress.
4 “Solu-Medrol” is a trademark for methyl-prednisolone sodium succinate. Dorland’s
Illus. Med. Dict. 1703 (33rd ed.). Methylprednisolone, in turn, is an anti-inflammatory and
immunosuppressant. Id. at 1137.
2

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experts retained for this litigation agree with the diagnosis of NMO. Dr. Sloane prescribed
Rituxan. Exhibit 3 at 206, 208.5
Mr. Farrell’s physical therapy, which started during the hospitalization, continued on an
out-patient basis. Mr. Farrell attended physical therapy roughly once every other week for five
sessions from March 17, 2017 to May 5, 2017. Exhibit 2 at 52-67. At the end of this period, Mr.
Farrell reported that he had improved and was planning to return to work. Id. at 64.
Mr. Farrell saw his neurologist, Dr. Sloane, in follow-up on June 15, 2017. Dr. Sloane
documented that Mr. Farrell had returned to work as an electrician, working on power lines, but
he is “clumsier, running into things/tripping or squeezing things too tightly in his hands.”
Exhibit 3 at 216. Dr. Sloane also recorded that Mr. Farrell was continuing “to have pain in his
lower back especially when he bends over. It is an electrical pain that shoots down his spine and
into his legs. It is much worse in the heat.” Id.
Dr. Sloane also explained how the disease was affecting Mr. Farrell:
Overall, he has noted that he becomes very tired easily and has
trouble getting out of bed. He feels depression and is having
trouble sleeping. Also has low energy levels, decreased
concentration. He does not want to take any medications for
depression. He feels overwhelmed by the diagnosis but is slowly
starting to adapt.
Id. at 215. Although Mr. Farrell’s motor strength was normal, he had decreased sensation. Id. at
217. His gait was narrow based. Dr. Sloane ordered more imaging, which showed the previous
lesions had resolved. Id. at 247-48 (July 6, 2017).
In August, Mr. Farrell missed work due to illness. Exhibit 57 at 63. Apparently, he had a
flare-up of symptoms in the hot weather. See Exhibit 2 at 68. In early August, he received three
more infusions of Solu-Medrol. Exhibit 3 at 223-229.
Dr. Sloane saw Mr. Farrell again on September 18, 2017. Exhibit 3 at 232. Dr. Farrell
documented that Mr. Farrell was on short-term disability and would continue for “the full
duration of several months allowable.” Id. at 233. A new problem was “pressure/achyness to the
L foot sole.” Id. at 232. Dr. Sloane’s impression included that Mr. Farrell has “intermittent pain
issues.” Id. at 235.
Following this appointment with Dr. Sloane, Mr. Farrell resumed physical therapy. From
September 22, 2017 to December 8, 2017, Mr. Farrell had five sessions. Exhibit 2 at 68-82.
These records note, without much detail, that Mr. Farrell had pain. The final report is not
particularly informative, stating that Mr. Farrell has good capacity for advancement.
5 Rituxan “is an anti-CD19 monoclonal antibody that targets B cells that have that
receptor.” Tr. at 106. Rituxan is a trademark for a preparation of rituximab. Dorland’s at 1623.
3

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Mr. Farrell returned to Dr. Sloane on December 14, 2017. Exhibit 3 at 242-45. Dr.
Sloane recorded that “He is trying to get a more sedentary job so his health is not at risk.” Id. at
242. Generally, the December 14, 2017 record resembles the September 18, 2017 record,
including a note that Mr. Farrell is having “intermittent pain issues.” Id. at 245. Dr. Sloane
added a prescription for tramadol for pain control. Id.6
Mr. Farrell sought a second opinion about NMO from a neurologist, Salvatore Napoli.
Exhibit 4 at 2 (Dec. 19, 2017). The history of present illness recounts that “The main issue now
appears to be the pain.”7 More specifically, “he has cramping of the feet, he has [tightening] of
his legs and feet” and “he will have severe pain of his lower back as well.” Id. Dr. Napoli’s
examination more or less matched what Dr. Sloane had been finding. Dr. Napoli’s assessment
included that Mr. Farrell “has residual pain in the lower extremities, spasticity, as well as
difficulties with his gait. . . . Our plan will be to continue rituximab therapy or even transition to
ocrelizumab.” Id. at 4. Dr. Napoli continued that Mr. Farrell’s “main issue of pain may also be
related to spasticity so we will start him on baclofen and I will give him Vicodin as needed. . .
We may also consider tizanidine or medicinal cannabinoid.” Id.
In the next two appointments, Mr. Farrell continued to complain about pain, although the
pain improved slightly. Exhibit 4 at 6-13. At the end of January 2017, Mr. Farrell had a flare of
neck pain, which Dr. Napoli characterized as a Lhermitte’s-like phenomenon. Id. at 14-25.
Mr. Farrell participated in another course of physical therapy in February 2018. Exhibit
42. He attended about five sessions. In the initial evaluation, the physical therapist obtained a
history of Mr. Farrell’s neurologic problem. In this context, the therapist noted: “He is struggling
with the mental health aspect of dealing with a disabling disease and feels overwhelmed with the
treatment and prognosis.” Id. at 97. He reported becoming fatigued when walking 15 minutes.
Id. He had a numbing pain in his both feet, which ranged from 3-7, and sharp pain in his
cervical spine, which ranged from 3-7. Id. The last physical therapy appointment was on
February 27, 2018. Id. at 38. Mr. Farrell appeared to have apologized for canceling sessions in
the previous week, explaining, “‘The depression of all this is getting to be too much.’” The
assessment also reflects this concern: “Pt notes extreme difficulty dealing with chronic pain,
overwhelming nature of dealing with potential disability from work, mounting expenses.” Id. at
39.
By the middle of February, Mr. Farrell was requesting that Dr. Napoli prescribe stronger
medication for pain, such as oxycodone. Dr. Napoli gave him a one-month supply but stated that
Mr. Farrell should seek assistance from pain management. Exhibit 4 at 27. Although the
oxycodone helped, within about two weeks, Mr. Farrell reported “pain is all over but worse on
the R side in both the arm and the leg, some burning quality.” Id. at 30 (Mar. 1, 2018). Dr.
6 “Tramadol hydrochloride” is an “opioid analgesic used for the treatment of moderate to
moderately severed pain.” Dorland’s at 1920.
7 Some of Dr. Napoli’s records are written in all capital letters. This decision uses more
traditional capitalization without specifically noting the alteration.
4

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Napoli added another medication, Cymbalta.8 Although Dr. Napoli considered referring him to
physical therapy, Mr. Farrell said that physical therapy is painful. Id. at 31.
On March 8, 2018, Mr. Farrell reported concerns about the effectiveness of Cymbalta in
controlling his pain. Exhibit 4 at 34. Dr. Napoli increased the dose of Cymbalta. Id. at 35. Dr.
Napoli stated: “patient is disabled from all gainful employment.” Id. at 35.
With the increase in oxycodone, Mr. Farrell’s pain improved from 8/10 to 6/10. Exhibit 4
at 38 (Mar. 16, 2018). In this visit, Mr. Farrell informed Dr. Napoli that he (Mr. Farrell) thinks
he has not “ever returned to baseline after initial attack last March.” Id. at 39.
Due to the continued pain, Dr. Napoli introduced a new medication, Acthar.9 Exhibit 4 at
42 (Mar. 20, 2018). Mr. Farrell returned to Dr. Napoli about two weeks later again stating he
“has been in pain all the time.” Id. at 46. Dr. Napoli also documented that Mr. Farrell got “a pill
from his friend. A urine test did show positive fentanyl.” Id. Dr. Napoli and his nurse
practitioner, Stacey Murray, spoke to Mr. Farrell about their policy and planned to taper Mr.
Farrell off oxycodone. Then, Mr. Farrell was expected to resume pain management. Id. at 47.
About two weeks later, Mr. Farrell was promising to go to pain management. Exhibit 4 at
51 (Apr. 20, 2018). In the meantime, Mr. Farrell stated that “he has stopped taking opiate-based
medications.” Id. Dr. Napoli advised that due to Mr. Farrell’s weakness, he should be on
disability. Id.10
As Dr. Napoli had been recommending, Mr. Farrell saw a specialist in pain management,
Sherif Algendy, on April 25, 2018. Exhibit 8. Mr. Farrell reported neck and lower back pain that
averaged 7 out of 10 with a 10 being the worst pain. Id. at 1. The history reports that Mr. Farrell
stopped oxycodone 24 days ago. The plan was to increase the dosage of Cymbalta. Another
alternative was to try CBD. Id. at 3.
Mr. Farrell returned to Dr. Napoli on January 11, 2019. Exhibit 44 at 108. The reason for
this appointment was “NMO/letter.” Dr. Napoli recorded that although Mr. Farrell was “feeling
improved,” “he is still having chronic issues, feet, hip, and back.” Id. Other specific problems
included feeling squeezed like by a band, a difficulty with urination, a difficulty with moving his
8 Cymbalta is a trademark for duloxetine hydrochloride. Dorland’s at 452. Duloxetine
hydrochloride, in turn, is a medication “used for the treatment of major depressive disorder and
the relief of pain in diabetic neuropathy.” Id. at 566.
9 Acthar is a trademark for corticotropin. Dorland’s at 21. Corticotropin, in turn,
stimulates the production of corticosteroids. Id. at 416-17.
10 A medical record from December 31, 2024 states that Mr. Farrell had a fentanyl
overdose in 2021. In this context, Mr. Farrell reported that he had “past opioid addiction due to
frequent pain in the setting of neuromyelitis optica.” Exhibit 55 at 45. Another December 2024
medical record suggests that opioid addiction occurred prior to 2021 as Mr. Farrell “detoxed in
2017.” Id. at 68.
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bowels, and leg fatigue and weakness. Id. at 108. Dr. Napoli ordered labs and prescribed
medications.
This appointment with Dr. Napoli led to another course of physical therapy, which started
on January 15, 2019. Exhibit 45 at 73. Mr. Farrell stated that he “feels like always being
squeezed tight or wearing [a] belt.” Id. Before his injury, he walked 1-2 miles with a dog.
Currently, he could walk about 0.25 miles and he tripped when he did not pick up his boots. He
again reported pain in his back and both feet. The physical therapist observed problems with Mr.
Farrell’s gait. Id. at 76.
Mr. Farrell attended about 17 sessions of physical therapy at the beginning of 2019. He
did not attend an appointment scheduled for May 22, 2019 because he planned to exercise at his
house. Exhibit 45 at 3. In the previous session, which was May 1, 2019, he reported that his
“walking is getting better and that he is getting more strength in his legs.” Id. at 7.
Mr. Farrell returned to Dr. Napoli’s practice on May 16, 2019, when he saw Nurse
Practitioner Murray. Exhibit 44 at 99. The chief complaint was: “Follow up NMO. SS
[probably Social Security] hearing 5/21/2019.” Mr. Farrell reported that “he has been feeling
‘okay.’” Id. Mr. Farrell “continues to have ‘tightening’ sensations, occasionally described as
electrical shock in the spine or in the legs. [T]his is intermittent but ‘when it happens it is
severe.’” Id. The plan was continuing his medication, Ocrevus. Dr. Napoli and Ms. Murray
supported his application for benefits because Mr. Farrell “can no longer perform his job
function[s].” Id. at 100.
Across the next approximately 18 months, Mr. Farrell returned to Dr. Napoli’s practice
approximately every month. Exhibit 44 at 39-97. During this time, Mr. Farrell continued to
receive various treatments. See, e.g., id. at 82 (Dec. 17, 20219 for Ocrevus), at 77 (May 6, 2020
for medical marijuana), at 63 (June 25, 2020 for Solumedrol), at 52 (July 13, 2020 for
Rituximab), at 47 (Aug. 7, 2020 for Botox). Occasionally, Mr. Farrell reported exacerbations.
See, e.g., id. at 56 (June 29, 2020).
Mr. Farrell reported another exacerbation on December 31, 2020. Exhibit 44 at 36.
Despite treatment, Mr. Farrell did not improve. Thus, on January 12, 2021, he sought care from
the emergency department at Newton-Wellesley Hospital. Exhibit 46 at 3. He complained about
lower abdominal pressure, including urinary retention and an inability to move his bladder.
Medical personnel consulted neurologists at Massachusetts General Hospital. Dr. Michael Levy
offered to admit Mr. Farrell to his service but no beds were available. Id. at 9. So, Mr. Farrell
was admitted to Newton-Wellesley Hospital.
While in the hospital, Mr. Farrell underwent a series of tests, including another round of
MRIs. The MRI of the cervical spine and thoracic spine showed degenerative changes. Exhibit
46 at 41, 50. The doctor responsible for his treatment considered these results to be unrevealing.
Id. at 23. Mr. Farrell was discharged on January 13, 2021. Id. at 23.
On February 23, 2021, Dr. Levy saw Mr. Farrell virtually for a new patient consult.
Exhibit 43 at 25-27. On June 15, 2021, Dr. Levy saw Mr. Farrell again and assessed that Mr.
Farrell was “a 45[-year-old] gentlemen with seronegative, monophasic neuromyelitis optica in
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2017 following a vaccination.” Id. at 15. Dr. Levy stated that Mr. Farrell “remains on rituximab
which may be preventing future relapses.” Dr. Levy also memorialized that “Symptoms
continue to flare periodically approximately twice per year.” Dr. Levy advised Mr. Farrell to
follow-up in about six months. Id. at 18.
On December 7, 2021, Mr. Farrell returned to see Dr. Levy in-person. Dr. Levy stated
that Mr. Farrell has “been managed with high-dose steroids and rituximab.” Exhibit 43 at 3. Dr.
Levy memorialized that “Mr. Farrell reports that he weaned off Lyrica and only uses marijuana
and it works for him. He still feels the neuropathy in his feet, which is a little uncomfortable.”
Id. “Currently, his neurological function is improving. He is exercising every day and walking.
He eats well and feels healthy. He feels some sensation feelings in his hands that comes and
goes.” Id. “For preventive treatment, Mr. Farrell previously used rituximab, last used in January
in 2021. He is no longer using rituximab as there is no indication that he is at risk for recurrent
disease.” Id. Mr. Farrell again expressed an interest in returning to work by, perhaps, using
medical marijuana. Id. at 8.
In between appointments with Dr. Levy in 2021, Mr. Farrell returned to Dr. Napoli’s
practice. See Exhibit 50.
Medical appointments in 2022 appear relatively infrequent. On June 22, 2022, Mr.
Farrell saw Dr. Napoli. Mr. Farrell “reports feeling good. He hasn't been in the hospital in over
a year which he feels really good about. He was stating that he did not have the greatest first few
years when he was first diagnosed with MS but today he feels great. No complaints.”11 Exhibit
50 at 7. Under the history of present illness, Mr. Farrell denied “any new issues. He has been
limited in his medicine use. He takes Lyrica as needed.” Dr. Napoli added that his “main
symptoms are hip and neck pain. He has spasticity and leg pain and leg fatigue with any
prolonged distance.” Id. Dr. Napoli recommended repeat MRIs.
On February 14, 2023, Mr. Farrell returned to see Dr. Levy and Dr. Anderson. Exhibit 51
at 4. For the interval history, Mr. Farrell reported general improvement:
Mr. Farrell states that he has been keeping active and feels that he
has almost returned to his baseline. He is currently retired from his
previous occupation. He still does not think his balance is where it
needed to be to continue with that occupation. [Review of systems]
was negative other than paresthesias in the feet at night, persistent
urinary retention, and occasional "flashes" in his vision at night.
He was even able to walk up 7 flights up for today's appt. He is not
currently on any medications other than Adderall and occasional
marijuana gummies at night for sleep.
Id. at 2. Mr. Farrell was advised to follow up in two years. Id. at 4.
The theme of general improvement is also reflected in an August 8, 2023 medical record
prepared by a nurse practitioner in Dr. Napoli’s practice, Beverly Wang. Exhibit 50 at 5-6. Ms.
11 The reference to MS (or multiple sclerosis) is mistaken.
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Wang memorialized that Mr. Farrell is currently not on any disease modifying therapy. He
occasionally gets “pain in the neck or feet with weather changes.” Id. at 5. Although Dr. Napoli
had recommended repeat MRIs in June 2022, Mr. Farrell had not gotten them. Mr. Farrell again
deferred more MRIs. The plan was for follow up in six months.
By the next appointment, which was by video on April 12, 2024, Mr. Farrell had not
obtained another set of MRIs. Exhibit 50 at 3. Mr. Farrell reported “neuropathic pain in his
bilateral feet; reports this returned about 3-4 weeks ago as he has been on his feet more at work.”
Id. Dr. Napoli prescribed Lyrica and again ordered MRIs.
At the end of December 2024, Mr. Farrell was hospitalized for significant cardiac
problems. Exhibit 55 at 49. He received treatment for heart failure in 2025. Exhibit 55, passim.
B. Affidavits
Mr. Farrell submitted two affidavits, both filed relatively early in the litigation. In his
first affidavit, which was signed on May 3, 2019, Mr. Farrell described his initial hospitalization
in March 2017. Mr. Farrell “thought [he] might die.” Exhibit 10 ¶ 1. Mr. Farrell also recounted
that he had difficulty returning to work and the “emotional and financial worries [he has] when
this first happened and still have [are] difficult to describe. [His] role as the breadwinner,
husband, & father was threatened.” Id. ¶ 2. He further averred that he “spend[s] many long,
lonely days wondering if [his] life will ever get back to normal.” Id. ¶ 3.
Mr. Farrell provided some general information about his potential damages in an affidavit
that was also signed in May 2019. Exhibit 11. Mr. Farrell stated that activities that he could no
longer enjoy included: playing with his children, driving long distances, walking long distances,
running, and working in the yard. Id. ¶ 10.
Although Mr. Farrell was invited to testify at the hearing, he did not testify. However,
Mr. Farrell and his family attended the hearing.
C. Testimony from Treating Doctors
As discussed below, Mr. Farrell presented reports and oral testimony from Dr. Napoli and
Dr. Levy. In particular, Dr. Napoli emphasized that Mr. Farrell wanted to return to work. Tr. 25-
27, 107-109. Dr. Napoli stated that Mr. Farrell “had scars to the battle that still remains.” Tr.
108. Dr. Napoli worried that problems with stamina might impair Mr. Farrell’s ability to work.
Tr. 109.
II. Procedural History12
Mr. Farrell initiated this case by filing a petition on February 26, 2019. The Secretary
evaluated this material and recommended that compensation be denied. Resp’t’s Rep., filed
pursuant to Vaccine Rule 4, on March 12, 2020. In the Secretary’s view, Dr. Napoli’s January 28,
12 A more extensive procedural history can be found in the July 29, 2025 Entitlement
Ruling.
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2019 letter was insufficient to establish that the tetanus vaccine caused Mr. Farrell’s NMO. Id. at
9-10.
The parties developed evidence from experts over the next few years. For Mr. Farrell,
Dr. Napoli wrote two reports: Exhibit 12, filed October 26, 2020; and Exhibit 39, filed June 4,
2021. Dr. Levy also wrote two reports: Exhibit 34, filed May 14, 2021; and Exhibit 41, filed
November 23, 2021.
The Secretary’s pair of experts wrote a total of five reports. Dr. He’s reports are Exhibit
A, filed March 1, 2021; Exhibit E, filed October 5, 2021; and Exhibit G, filed January 24, 2022.
Dr. Cohen’s reports are Exhibits C, filed March 1, 2021; and Exhibit F, filed October 5, 2021.
Periodically, the topic of settlement was raised. On some occasions, the Secretary
declined to explore an informal resolution. See Resp’t’s Status Rep., filed Jan. 27, 2020;
Resp’t’s Status Rep., filed Aug. 6, 2021; Order, issued Mar. 11, 2022; Order, issued April 17,
2024; Order, issued Aug. 8, 2024.13 In any event, the parties did not reach a settlement, and the
case proceeded to a hearing.
After a hearing and briefing, Mr. Farrell was found entitled to compensation. Entitlement
Ruling, issued July 29, 2025, 2025 WL 2409187.. As part of the process for determining the
amount of damages, Mr. Farrell anticipates claiming a substantial amount of compensation for
his lost earnings. See order, issued July 23, 2025. Whether this claim is justified to any extent
remains undetermined.
Mr. Farrell requested an award of compensation on an interim basis via the pending
motion, filed on Aug. 28, 2025. Mr. Farrell presents essentially three points: (1) as a matter of
law, interim awards of compensation are available to petitioners in the Vaccine Program; (2) as a
matter of discretion, he should receive an interim award of compensation; and (3) an appropriate
amount of compensation for his pain, suffering, and emotional distress is $250,000. The
Secretary opposes and challenges each of the three points as discussed below. Resp’t’s Resp.,
filed Sep. 9, 2025. Mr. Farrell defended his request. Pet’r’s Reply, filed Sep. 26, 2025. With the
submission of the reply, the motion is ready for adjudication.
III. Analysis Part One: Are Interim Awards of Compensation Available to Petitioners in
the Vaccine Program?
Interim awards of compensation have happened before. The parties cite the same series
of cases. See Pet’r’s Mot. at 2-3; Resp’t’s Resp. at 2-3. In chronological order, starting with the
earliest, these are: Lerwick v. Sec’y of Health & Hum. Servs., No. 06-847V, 2014 WL 1897656
(Fed. Cl. Spec. Mstr. Apr. 16, 2014); Day v. Sec’y of Health & Hum. Servs., No. 12-630V, 2016
WL 3457749 (Fed. Cl. Spec. Mstr. May 31, 2016), mot. for rev. denied, 129 Fed. Cl. 450 (2016);
Fairchild v. Sec’y of Health & Hum. Servs., No. 13-487V, 2017 WL 6892899 (Fed. Cl. Spec.
Mstr. Dec. 1, 2017), mot. for rev. denied, 138 Fed. Cl. 29 (2018), app. dismissed, No. 2018-2320,
13 It appears that the Secretary may have communicated an offer. See Pet’r’s Status Rep.,
filed July 11, 2024.
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2018 WL 11450386, at *1 (Fed. Cir. Dec. 28, 2018); and Schettl v. Sec’y of Health & Hum.
Servs., No. 14-422V, 2020 WL 1912224 (Fed. Cl. Spec. Mstr. Mar. 25, 2020).
The Secretary notes that these opinions do not create binding precedent. This is true.
Boatmon v. Sec’y of Health & Hum. Servs., 941 F.3d 1351, 1358 (Fed. Cir. 2019).
On the other hand, the Secretary does not meaningfully engage with these opinions’
reasoning. For example, the Secretary contends that the “Vaccine Act does not contemplate
multiple damages judgments in the same case.” Resp’t’s Resp. at 3. Yet, in those cases, multiple
damages judgments were issued.
Moreover, in two cases, the Secretary challenged a special master’s determination that
interim awards of compensation are available by filing a motion for review. (The Secretary did
not challenge the ruling finding entitlement to compensation.) In both cases (Day and Fairchild),
the Court of Federal Claims, which reviewed the special master’s holding that the Vaccine Act
allows for interim awards of compensation without deference, also held that petitioners may
receive an interim award of compensation. Finally, to the extent that the Secretary were
concerned about this interpretation, the Secretary could have appealed to the Federal Circuit.
The Secretary took advantage of this option in Fairchild but then dismissed the appeal.
Mr. Farrell makes a similar argument with respect to the Fairchild appeal to the Federal
Circuit that the Secretary dismissed:
If the Secretary wanted to maintain arguments against awards of
compensation on an interim basis, it is incumbent on respondent to
file a motion for review and, if necessary, to file an appeal so that
judges can resolve the issue. Consistently raising an argument
before special masters without taking the steps to obtain a
definitive interpretation wastes resources of litigants and special
masters.
Pet’r’s Reply, at 3, citing Nuttal v. Sec’y of Health & Hum. Servs., No. 07–810V,
2011 WL 5926131, at *2 (Fed. Cl. Spec. Mstr. Nov. 4, 2011) (discussing the
Secretary’s arguments against awarding attorneys’ fees and costs on an interim
basis).
In accord with the non-binding authorities cited above, the undersigned holds that awards
of interim compensation are available to petitioners in the Vaccine Program.
IV. Analysis Part Two: Is an Interim Award of Compensation Appropriate for Mr.
Farrell?
Although as a matter of statutory interpretation interim awards of compensation are
consistent with the Vaccine Act, petitioners are not always entitled to an interim award. Instead,
special masters exercise discretion in determining whether an award is appropriate.
The parties differ. Mr. Farrell emphasizes that the litigation has been pending for more
than six years (Pet’r’s Mot. at 2) and that a lack of gainful employment has made him “in dire
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need of financial assistance” (Pet’r’s Mot. at 11). In contrast, the Secretary suggests that if
interim awards of compensation are allowed, then they should be reserved for cases with
extraordinary circumstances. Resp’t’s Resp. at 4, citing Day, 2016 WL 3457749, at *5. The
Secretary argues that Mr. Farrell has not presented evidence documenting his financial
circumstances and points out that he received a payment for his injury via a Workers’
Compensation claim. The Secretary also notes that the resolution of the damages portion of the
case has not been protracted. Id. at 5. Finally, the Secretary suggests that the Secretary’s defense
of the entitlement portion of the claim should weigh against an award of compensation on an
interim basis because “a motion for review of the ruling on entitlement is being seriously
contemplated.” Id. at 7.
Although Day appears to be limit interim decisions awarding compensation to
extraordinary circumstances, the undersigned is not sure that they should be so restricted. Three
factors support making interim compensation decision more available. First, the general oft-
repeated policy of the Vaccine Program is “to award compensation to vaccine-injured persons
quickly.” Cottingham v. Sec’y of Health & Hum. Servs., 971 F.3d 1337, 1343 (Fed. Cir. 2020);
accord Koston v. Sec’y of Health & Hum. Servs., 947 F.2d 157, 161 (Fed. Cir. 1992). An interim
award, which delivers at least some compensation, more speedily is in accord with Congress’s
purpose.
Here, Mr. Farrell has qualified as someone who has demonstrated with preponderant
evidence that a vaccine harmed him.14 Thus, resolution of the amount of compensation to which
he is entitled should happen “quickly.” But this tends not to happen.
The time for determining damages is the second reason supporting an interim award of
compensation. The process for resolving damages when petitioners seek compensation for
unreimbursed medical expenses via a life care plan and compensation for lost future earnings
tends to take at least one year minimum. In the damages phase, the parties tend to cooperate.
After a ruling finding entitlement in off-Table cases, most cases are resolved via a proffer. The
parties deserve credit for reaching agreements with each other that minimize the number of
issues in damages that the special masters are called upon to resolve.
14 Although the Secretary states that he might file a motion for review challenging the
Entitlement Ruling, this factor plays almost no role in determining whether Mr. Farrell should be
awarded compensation on an interim basis. The Secretary possesses a right to contest
entitlement by seeking further review. But, the Secretary’s right does not prevent Mr. Farrell
from exercising his right to seek an award of compensation on an interim basis. Moreover, if
anything, the possibility that the Secretary might challenge the entitlement ruling seems to
support an earlier decision awarding a portion of the compensation to which Mr. Farrell might be
entitled. If the entitlement ruling were overturned sooner, then the parties would not devote so
much time and resources to determining the amount of compensation. See, e.g., Dobrydnev v.
Sec’y of Health & Hum. Servs., 566 Fed. App’x 976 (Fed. Cir. 2014) (reinstating a special
master’s decision that petitioner was not entitled to compensation and reversing judgment
awarding compensation).
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These good-faith efforts from the parties necessarily take time. In general, neither
petitioners nor respondent are necessarily at fault for time it takes to process damages. It is
usually the case that complicated issues simply require the input of many busy professionals.
Third, the time for processing damages hurts petitioners, who are awaiting compensation.
The delay cannot be compensated because special masters cannot award interest. Edgar v. Sec’y
of Health & Hum. Servs., 29 Fed Cl. 339, 344 (1993). The significance of a lack of interest can
be illustrated in a chart based upon interest compounded once per year.
Date Value to Mr. Value to Mr. Value to Mr.
Compensation Amount Interest Farrell on Farrell on Farrell on
Awarded
Awarded Rate 11/1/2025 11/1/2026 11/1/2027
11/1/2025 $210,000 4% $210,000 $218,400 $227,136
11/1/2026 $210,000 4% none $210,000 $218,400
11/1/2027 $210,000 4% none none $210,000
The three different rows reflect three scenarios. The first row (compensation awarded on
Nov. 1, 2025) reflects an award of interim compensation. The second row (compensation
awarded on Nov. 1, 2026) reflects a potentially optimistic resolution of damages with the
damages process taking about one year. The third row (compensation awarded on November 1,
2027) reflects a more protracted process.
As this chart illustrates, an award of compensation to Mr. Farrell on an interim basis
delivers money for his use and enjoyment more quickly and the earlier award of compensation
results in a greater amount of money from his perspective. As someone who is entitled to
compensation, Mr. Farrell should receive some compensation as quickly as possible. Thus, he is
not required to demonstrate extraordinary circumstances.15 Therefore, awarding Mr. Farrell
compensation on an interim basis is appropriate.
V. Analysis Part Three: What Is A Reasonable Amount of Compensation for Pain,
Suffering, and Emotional Distress?
The Vaccine Act provides statutory guidance regarding awards for pain and suffering.
15 On the other hand, as a practical matter, limits on judicial resources may preclude
interim awards of compensation routinely. In the roughly analogous circumstance of awards of
attorneys’ fees and costs, sometimes special masters prioritize resolving amounts of final fees
over resolving amounts of interim fees. This prioritization of some cases is an inevitable part of
docket management. See Landis v. N. Am. Co., 299 U.S. 248, 255-55 (1936) (recognizing trial
courts’ discretion to manage their dockets); Amado v. Microsoft Corp., 517 F.3d 1353, 1358
(Fed. Cir. 2008) (trial courts “are afforded broad discretion to control and manage their dockets,
including the authority to decide the order in which they hear and decide issues pending before
them”).
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Case 1:19-vv-00301-UNJ Document 165 Filed 12/10/25 Page 13 of 15
Compensation awarded under the Program to a petitioner
under section 300aa-11 of this title for a vaccine-related injury or
death associated with the administration of a vaccine after October
1, 1988, shall include the following: . . . .
(4) For actual and projected pain and suffering and emotional
distress from the vaccine-related injury, an award not to exceed
$250,000.
42 U.S.C. § 300aa-15. “Successful claimants receive compensation for medical, rehabilitation,
counseling, special education, and vocational training expenses; diminished earning capacity;
pain and suffering; and $250,000 for vaccine-related deaths.” Bruesewitz v. Wyeth LLC, 562
U.S. 223, 229 (2011).
With respect to the amount of compensation, the parties’ advocacy could have been
better. Mr. Farrell seeks the maximum amount. Pet’r’s Mot. at 13. However, he did not cite any
analogous cases. The Secretary did not propose any amount as reasonable. See Resp’t’s Resp. at
7-8. The Secretary also fails to cite any comparable cases. Instead, the Secretary points out that
a January 12, 2021 MRI of Mr. Farrell’s spine shows that he has developed degenerative
changes. Id. at 8, citing Exhibit 46 at 41. Thus, the Secretary argues that an evaluation of Mr.
Farrell’s pain and suffering should be deferred until the record is further developed by obtaining
opinions from an expert.
The Secretary’s contention that further development is required is misguided for at least
two reasons. First, the record already contains the opinion of two experts, Doctors Napoli and
Levy. To the extent that the Secretary wanted to counter these opinions, the Secretary has not
shown that he has taken any steps to do so. For example, during the entitlement phase, the
Secretary retained a neurologist, Dr. Cohen, and presumably, Dr. Cohen, remains available to
comment upon whether problems Mr. Farrell experienced after January 2021, when the MRI
detected degenerative changes, were attributable to NMO. Actually, Dr. Cohen agreed that Mr.
Farrell has “had significant neurological deficits.” Tr. 234. The Secretary did not propose any
schedule by which he might present the opinions of an expert. Mr. Farrell does not have to wait.
Second, and more importantly, the Secretary’s argument appears to focus on the trees, not
the forest. At the broad level, Mr. Farrell was diagnosed with NMO, and the Secretary does not
dispute the diagnosis. See Exhibit C (Dr. Cohen’s report) at 5. The onset was in March 2017.
This means that he has suffered from NMO for more than eight years. Although Mr. Farrell
experienced other health problems during these eight years, none of those other problems
eliminate NMO. Furthermore, there is ample information about Mr. Farrell’s physical and
mental health from the NMO. The Secretary could have analyzed this evidence to propose an
amount of compensation for the pain, suffering, and emotional distress that flowed from Mr.
Farrell’s NMO. Except for citing the January 2021 MRI and one other record, the Secretary’s
response to Mr. Farrell’s motion for an award for his pain, suffering, and emotional distress omits
any discussion of Mr. Farrell’s medical records. The Secretary’s failure to propose a specific
number may be interpreted as a waiver of any argument regarding the amount of the pain and
suffering. See Vaccine Rule 8(f).
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Highlights from the evidence about Mr. Farrell’s pain, suffering, and emotional distress
include the following:
• He was hospitalized for about five days in March 2017. Exhibit 3 at 7.
• During this time, Mr. Farrell feared he might die. Exhibit 10 ¶ 1.
• NMO affected Mr. Farrell’s mental well-being. Exhibit 3 at 215, Exhibit 42 at 97;
see also Exhibit 50 at 7.
• NMO complicated his employment. Thus, Mr. Farrell worried about the financial
circumstances for his family and his himself.16
• From onset in March 2017 to about February 2021, Mr. Farrell’s problems waxed
and waned for which he took a variety of medications. His symptoms flared
about twice per year. Exhibit 43 at 15.
• By the end of 2021, Mr. Farrell was taking relatively little medication to control
his residual problems such as paresthesias. Exhibit 43 at 3, Exhibit 50 at 7.
• Despite Dr. Napoli’s recommendation, Mr. Farrell did not obtain additional MRIs
after June 2022. See Exhibit 50 at 3. This lack of follow up suggests that the
neurologic problems were not weighing heavily on Mr. Farrell’s mind.
In short, Mr. Farrell experienced four rough years (March 2017 to February 2021). But,
the approximately 4.5 years from February 2021 to the present have been comparatively good.
When considered as a whole, the evidence preponderantly supports an award for pain,
suffering, and emotional distress at $210,000. This amount compensates for pain, suffering, and
emotional distress incurred through September 1, 2025. Mr. Farrell remains eligible for an
additional award of pain, suffering, and emotional distress incurred after September 1, 2025.
16 Mr. Farrell’s worries about his financial problems are noted. However, this aspect
does not contribute significantly to the assessment of his pain, suffering, and emotional distress
as the evidence is not complete.
A family’s finances depend upon both money received and money spent. Mr. Farrell has
presented negligible information about spending money.
For the other side of the ledger concerning receiving money, Mr. Farrell’s evidence is
also not complete. Although Mr. Farrell states that after his NMO, he has worked little (Pet’r’s
Status Rep., filed Sep. 22, 2025), medical records refer to him working at least sometimes. See
Exhibit 55 at 49, 60 (stating he worked until 2022), and 148. Further, Mr. Farrell received
money through Workers’ Compensation. Exhibit 56 at 8. He also is receiving disability benefits
through Social Security. Id. at 12.
The statement that evidence about Mr. Farrell’s financial problems is “incomplete” does
not mean that he has not worried about his finances. But, when a claim for pain, suffering, and
emotional distress is based, in part, on financial problems due to a vaccine-related injury, more
information about financial circumstances should be provided.
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Case 1:19-vv-00301-UNJ Document 165 Filed 12/10/25 Page 15 of 15
Some of this post-September 1, 2025 pain, suffering, and emotional distress might include pain,
suffering, and emotional distress that Mr. Farrell is expected to incur after the date of any
judgment, which is usually termed “future pain and suffering.” This topic will be discussed at
the next status conference. As just stated, the amount is based upon the evidence in Mr. Farrell’s
case. The amount of past pain, suffering, and emotional distress also appears consistent with
awards in cases with another demyelinating disease, Guillain-Barré syndrome. See, e.g.,Drcar v.
Sec'y of Health & Hum. Servs., No. 21-1766V, 2024 WL 5266648 (Fed. Cl. Spec. Mstr. Nov. 14,
2024) (awarding $200,000 in pain and suffering); Fiumara v. Sec'y of Health & Hum. Servs., No.
23-138V, 2024 WL 4930694 (Fed. Cl. Spec. Mstr. Oct. 30, 2024) (awarding $197,500 in pain
and suffering); Merchant v. Sec'y of Health & Hum. Servs., No. 20-0450V, 2022 WL 17819548
(Fed. Cl. Spec. Mstr. Nov. 7, 2022) (awarding $170,000 in pain and suffering). Although none of
these cases match Mr. Farrell’s case perfectly, they illustrate how special masters have
compensated people who have suffered from a demyelinating disease for about five years.
VI. Conclusion
Mr. Farrell established that his receipt of a vaccine caused him an injury. Congress
created the Vaccine Program to compensate people like Mr. Farrell. Here, the evidence supports
a finding that a reasonable amount of compensation for the pain, suffering, and emotional
distress that Mr. Farrell has incurred is $210,000.
A lump sum of $210,000 shall be paid through an ACH deposit to petitioner’s
counsel’s IOLTA account for prompt disbursement to petitioner.
The Clerk's Office is instructed to enter judgment in accord with this decision unless a
motion for review is filed. Information about filing a motion for review, including the deadline,
can be found in the Vaccine Rules, which are available on the website for the Court of Federal
Claims.
IT IS SO ORDERED.
s/Christian J. Moran
Christian J. Moran
Special Master
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