VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_19-vv-00479
Package ID: USCOURTS-cofc-1_19-vv-00479
Petitioner: Titus Henderson
Filed: 2019-04-01
Decided: 2022-07-26
Vaccine: Tdap
Vaccination date: 2016-04-14
Condition: injury of shoulder deltoid muscle and nerves, [and a] severe allergic (anaphylaxis) seizure reaction, etc.
Outcome: dismissed
Award amount USD: 

AI-assisted case summary:
Titus Henderson filed a petition alleging he received Tdap and influenza vaccines on April 14 and 16, 2016, which caused him to suffer shoulder injury and a severe allergic seizure reaction. Mr. Henderson, who was incarcerated at the time, faced significant challenges in obtaining his medical records, leading to numerous procedural filings and extensions. The Secretary of Health and Human Services recommended dismissal, stating Mr. Henderson failed to demonstrate a Table SIRVA injury because shoulder pain was not reported until over two years after vaccination, and he did not establish causation-in-fact for his other alleged injuries. The court found that the medical records did not specify which arm received the Tdap vaccine, nor did they show shoulder pain within 48 hours of vaccination, thus failing the criteria for a Table SIRVA claim. For the alleged seizure reaction and nerve damage, the court found Mr. Henderson did not provide a medical theory, a logical sequence of cause and effect, or a proximate temporal relationship between the vaccination and the alleged injuries, nor did his treating physicians support such a link. The court also noted that records suggested he had seizures prior to the vaccination. Ultimately, the court determined that Mr. Henderson had not provided persuasive proof of his claimed injuries and dismissed his petition for compensation.

Theory of causation field:
Off-Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_19-vv-00479-0
Date issued/filed: 2022-08-24
Pages: 14
Docket text: PUBLIC DECISION (Originally filed: 7/26/2022) regarding 52 DECISION of Special Master Signed by Special Master Christian J. Moran. (jmw) Service on parties made. (Main Document 53 replaced on 8/25/2022 to add the reissued date and the appropriate footnote regarding Vaccine Rule 18(b).) (fm). Petitoner served via U.S. Mail.
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Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 1 of 14
CORRECTED
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
** * * * * * * * * * * * * * * * * * * * * * * *
TITUS HENDERSON, *
* No. 19-479V
Petitioner, * Special Master Christian J. Moran
*
v. * Filed: July 26, 2022
* Reissued for Public Availability:
SECRETARY OF HEALTH * August 24, 2022
AND HUMAN SERVICES, *
* entitlement, SIRVA, seizure reaction
Respondent. *
* * * * * * * * * * * * * * * * * * * * * * * **
Titus Henderson, pro se, Green Bay, WI;
Mallori B. Openchowski, United States Dep’t of Justice, Washington, DC, for
respondent.
UNPUBLISHED DECISION DENYING COMPENSATION1
Representing himself, Titus Henderson alleged he received vaccinations on
April 14, 2016 and April 16, 2016, which caused him to suffer from an “injury of
shoulder deltoid muscle and nerves, [and a] severe allergic (anaphylaxis) seizure
reaction, etc.” Pet., filed Apr. 1, 2019, at pdf 2. After Mr. Henderson filed some
medical records, the Secretary of Health and Human Services (“the Secretary”)
reviewed that material and advised that he was not entitled to compensation.
Resp’t’s Rep., filed pursuant to Vaccine Rule 4, June 28, 2021. Mr. Henderson has
attempted to address the deficiencies the Secretary has identified. His case was
submitted for adjudication. For reasons that follow, Mr. Henderson is not entitled
to compensation and his petition is dismissed.
1 Pursuant to Vaccine Rule 18(b), this Decision was initially filed on July 26, 2022,
and the parties were afforded 14 days to propose redactions. The parties did not
propose any redactions. Accordingly, this Decision is reissued in its original form
for posting on the court’s website.

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 2 of 14
I. Procedural History
Mr. Henderson filed his petition on April 1, 2019, and with his petition, he
included a document (labeled exhibit 3) indicating he was a prisoner within the
Wisconsin Department of Corrections (“DOC”). See Pet., filed Apr. 1, 2019.2 The
petition refenced exhibits 1-3, though only exhibit 3 was received with the petition.
Contemporaneously, Mr. Henderson filed a motion for leave to proceed in forma
pauperis.3 This case was assigned to the undersigned special master on April 3,
2019.
Per the Vaccine Guidelines, Mr. Henderson was ordered to submit medical
records spanning the three years before the alleged vaccinations to the present. He
was also ordered to re-file exhibits 1 and 2, which appeared to be missing. See
Order, issued April 8, 2019.
On April 17, 2019, Mr. Henderson filed a document titled “ORDER to
Produce Titus Henderson’s Medical Records, and six (6) Month Trust Account
Statement.” See ECF #9. The document, authored by Mr. Henderson, directed the
Secretary of the Wisconsin DOC, Kevin Carr, to produce the titular documents and
send them to the undersigned. The filing included two Health Service Request
Forms (“HSR”) and Copayment Disbursement Authorization forms.4 The forms
indicate Mr. Henderson requested all of his health records, and that prison staff
advised him to pay for copies of those documents and/or have a lawyer request the
records. Mr. Henderson filed a complaint with the prison because “HSU won’t
send his vaccination files to the court.” Id.
Due to difficulty obtaining and forwarding records, Mr. Henderson moved
for an extension of time to file his medical records. Pet’r’s Mot., filed June 4,
2 The document (labeled exhibit 3 by petitioner) is titled “MEDICAL
RESTRICTIONS / SPECIAL NEEDS.” It indicates Mr. Henderson was
incarnated and was to take “Meals on Unit” between August 31, 2016 and
November 31, 2016. Exhibits 1 and 2 were not filed at this time. As discussed
herein, the undersigned ultimately assigned documents exhibit numbers to ensure
consistent references.
3 The motion indicates that Mr. Henderson was (in 2019) incarcerated at the
Green Bay Correctional Institution.
4 HSR forms contain the patient’s subjective complaints as opposed to notes
taken by a medical professional during an examination.
2

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2019. The motion alleges the Green Bay DOC Health Manager, Jean Lutsey, “has
concealed + destroyed medical files to hinder / deny” review of the case and
“refuse[s] to release other medical files without a Court Order.” Id. The motion
also asked the undersigned to order the prison to protect and produce the requested
medical files. Included with the motion is an April 12, 2019 Institution Complaint
Examiner’s report (complaint # GBCI-2019-6368), which stated that “files are not
released by inmate request when there are no court proceedings. [Health Services
Unit] needs to get request from the court to produce documents. Inmate
Henderson signed a consent to release documents but there was no request.
Recommendation: Dismiss.”
On June 20, 2019, the undersigned granted the extension of time, provided
confirmation that Mr. Henderson had initiated court proceedings, and implicitly
requested the documents. See Order, issued June 20, 2019. The order provided a
July 30, 2019 deadline. On July 2, 2019, Mr. Henderson moved for an extension
of time or suspension of proceedings. This indicated Mr. Henderson likely had not
received the June 20, 2019 order. Mr. Henderson’s July 2, 2019 motion also
suggested an attorney might be assisting him. The undersigned granted Mr.
Henderson’s motion to stay the proceedings for 30 days, allowing Mr. Henderson
until August 30, 2019 to file his medical records and to re-file exhibits 1 and 2.
On August 30, 2019, Mr. Henderson filed a 182-page document titled
“Proposed Findings of Facts,” which included medical records and other exhibits.
Given that the records submitted appeared to generally cover April 2013 to the
present, with some acknowledgments about missing records, the undersigned
ordered the Secretary to file a status report regarding his medical reviewer’s
assessment. See Order, issued Sept. 26, 2019.
The Secretary filed a status report, requesting additional time to evaluate the
completeness of medical records. Resp’t’s Status Rep., filed Nov. 25, 2019. The
undersigned granted the Secretary’s request and ordered him to file a status report
regarding the completeness of the records by January 24, 2020.
Subsequently, the Secretary moved to suspend proceedings in this case for at
least ninety days. Concerned about the number of petitions originating from
Waupun Correctional Institution, the Secretary indicated he would conduct an
investigation for potentially fraudulent activity. See Resp’t’s Mot. to Suspend
Proceedings, filed Dec. 23, 2019.
3

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The undersigned partially granted the Secretary’s motion, allowing an
additional thirty days for the Secretary to evaluate the medical records Mr.
Henderson had filed. See Order, issued Jan. 8, 2020.
On February 27, 2020, the Secretary renewed his request to stay
proceedings, noting similar cases were under evaluation with the Department of
Justice’s Office of the Inspector General.5 Considering that any pattern of fraud
would still need to be evaluated in the context of the facts and medical records
specific to this case, the undersigned denied the Secretary’s motion. See Order,
issued Mar. 6, 2020. The undersigned again ordered Mr. Henderson to file all
medical records between April 2013 and April 2016 and ordered the Secretary to
provide an update on his review of the materials in this case. Id.
On April 6, 2020, Mr. Henderson moved to suspend proceedings for eighty
days.6 Mr. Henderson indicated that the emerging Covid-19 pandemic and orders
issued by Wisconsin Governor Tony Evers caused prison staff to temporarily close
down the medical records office.
A few days later, the Secretary filed a status report requesting records
generally and specifically. Of particular importance, the Secretary requested “2.
Documentation of vaccination of both claimed vaccines (influenza, Tdap) . . . 3.
Any documentation regarding evidence of seizures, anaphylaxis, nerve damage . . .
[and] 4. Any and all records that would indicate the onset of symptoms.” Resp’t’s
Status Rep., filed Apr. 8, 2020.
On April 30, 2020, the undersigned granted Mr. Henderson’s motion to stay
proceedings for eighty days. Mr. Henderson was ordered to file his complete set of
medical records, including those identified by the Secretary, by July 17, 2020.
Next, on May 26, 2020, Mr. Henderson filed a document requesting the
undersigned issue an order to assist him in obtaining his medical records. On June
4, 2020, the undersigned issued an order (to be presented to the DOC) explaining
that Mr. Henderson requires complete versions of his medical records between
April 2013 and April 2016, as well as the specific records identified by the
5 The Secretary also identified “possible items outstanding.” He requested
compete records from the three years prior to the vaccination at issue “[t]o the
extent they exist.” But, the Secretary did not identify any specific records.
6 Some content within the motion is difficult to read due but the essence was
gleaned.
4

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 5 of 14
Secretary. The order stated Mr. Henderson may present the order to DOC officials
to facilitate gathering the medical records.
The July 17, 2020 deadline passed without any new records or updates from
Mr. Henderson. On August 13, 2020, the undersigned issued a similar order to the
May 26, 2020 order to help facilitate the collection of medical records. A new
deadline for Mr. Henderson’s records was set, sua sponte, for September 14, 2020.
Unable to obtain the requested records, Mr. Henderson again moved for an
order to produce the records held by the Wisconsin DOC. See Pet’r’s Mot., filed
Aug. 18, 2020. On September 1, 2020, the undersigned issued an order (to provide
explanation to Wisconsin DOC officials) reiterating that Mr. Henderson required
complete versions of his medical records.7 On September 6, 2020, Mr. Henderson
filed additional documentation evincing that he was attempting to obtain his
medical records; the letter that he filed indicated the DOC would release his
medical records after he provided a signed released form. See ECF #36.
Presumably due to administrative delays and workplace disruptions due to
Covid-19, a few months passed without any new filings. On November 30, 2020,
the undersigned issued a show cause order, requiring Mr. Henderson to
demonstrate why his case should not be dismissed for failure to prosecute his case.
Mr. Henderson responded on January 25, 2021. His response reiterated difficulties
obtaining his medical records and renewed his request that the undersigned compel
the Wisconsin DOC to produce his complete set of medical records. Subsequently,
on February 8, 2021, and February 12, 2021, Mr. Henderson filed more medical
records. See ECF #39, #40.
With the recent filings, it appeared that Mr. Henderson had filed all of his
medical records. On April 28, 2021, the undersigned issued an order requiring the
Secretary to evaluate the petition and medical records, and to file his Rule 4(c)
Report. To address inconsistencies in how Mr. Henderson’s exhibits had been
labeled, the order specified new exhibit numbers for each of the exhibits submitted.
See Order, issued Apr. 28, 2021 (sua sponte creating a consistent exhibit list for
petitioner).
On June 28, 2021, the Secretary filed his Rule 4(c) Report, which
recommended that the petition be dismissed for insufficient proof. The Secretary
7 Due to the timing of the filings, it appeared that Mr. Henderson had not yet
received the August 13, 2020 order.
5

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 6 of 14
identified numerous issues. Mr. Henderson had not demonstrated a Table SIRVA
injury because the record did not demonstrate that Mr. Henderson developed
shoulder pain within 48 hours of administration of the Tdap vaccine. See Resp’t’s
Rep. at 7. Shoulder pain was not reported or discussed with a medical provider
until August of 2018, more than two years after the Tdap vaccine. Id.; exhibit 3 at
27-28. Additionally, Mr. Henderson had not established causation-in-fact
regarding his other alleged injuries.
The undersigned ordered Mr. Henderson to file a response to the Rule 4(c)
Report with any evidence and/or arguments. See Order, issued June 29, 2021. On
September 7, 2021, Mr. Henderson moved for an extension of time because he had
not received the prior order until five days before his deadline. The same day, the
undersigned granted Mr. Henderson’s motion, providing him with an additional
month to muster his arguments and evidence. After the deadline passed without
any response, on October 22, 2021, the undersigned extended Mr. Henderson’s
deadline, sua sponte, until November 12, 2021. The deadline passed again without
a response. On November 29, 2021, the undersigned issued an order, permitting
Mr. Henderson a final opportunity to submit a response, resetting his deadline for
January 3, 2022.
Mr. Henderson’s response to the Secretary’s Report was received on
November 30, 2021. The response document contained two written pages and
appeared to be incomplete. In the interest of fairness, Mr. Henderson was provided
the opportunity to resubmit his filing by March 16, 2022. See Order, issued Feb.
16, 2022. After a few months passed without any response, it appeared the record
was complete. The undersigned issued an order on April 18, 2022 indicating this
case was submitted for adjudication.
II. Standards for Determining Facts
Petitioners are required to establish their cases by a preponderance of the
evidence. 42 U.S.C. § 300aa-13(a)(1). The preponderance of the evidence
standard requires a “trier of fact to believe that the existence of a fact is more
probable than its nonexistence before [he] may find in favor of the party who has
the burden to persuade the judge of the fact’s existence.” Moberly v. Sec’y of
Health & Hum. Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (citations
omitted).
The process for finding facts in the Vaccine Program begins with analyzing
the medical records, which are required to be filed with the petition. 42 U.S.C.
§ 300aa-11(c)(2). Medical records that are created contemporaneously with the
6

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 7 of 14
events they describe are presumed to be accurate. Cucuras v. Sec’y of Health &
Hum. Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993). However, medical records
may not always list all problems a person is experiencing. See Kirby v. Sec’y of
Health & Hum. Servs., 997 F.3d 1378, 1382 (Fed. Cir. 2021).
Pursuant to these standards for determining when events did or did not
happen, the undersigned finds how the evidence preponderates. In setting forth the
findings, the undersigned also cites to the primary evidence that is the basis for the
finding. The undersigned recognizes that not all evidence is entirely consistent
with these findings. See Doe 11 v. Sec’y of Health & Hum. Servs., 601 F.3d 1349,
1355 (Fed. Cir. 2010) (ruling that the special master’s fact-finding was not
arbitrary despite some contrary evidence).
III. Findings of Facts
Events in Mr. Henderson’s life can be divided into 3 periods. The first
period is Mr. Henderson’s health before he was vaccinated. The next period is the
months before and after April 2016. The last period covers the most recent
medical records. In the findings below, not every medical record is described, as
most of the records are not relevant to Mr. Henderson’s claims. The most relevant
records (with respect to timing and complaints germane to the petition) are
recounted.
A. Health Before Vaccination
Based on the submitted records, little can be gleaned regarding Mr.
Henderson’s health prior to the alleged vaccinations. He had a history of
hyperlipidemia, chronic abdominal pain, constipation, (exhibit 3 at 27) and PTSD
with reportedly related seizures. Exhibit 3 at 27; exhibit 4 at 47-48.8 Mr.
8 Mr. Henderson was evaluated by psychiatrist Joel Rigueur on August 17,
2016. Under history of present illness, Dr. Rigueur wrote the following: “Mr.
Titus Henderson presented with a history of posttraumatic stress disorder with a
history of being isolated for 15 years in isolation and a history of physical abuse
and has been having flashbacks and nightmares and being tortured with sequela of
seizures.” Exhibit 4 at pdf 47. This history suggests any seizures Mr. Henderson
may have been experiencing were related to PTSD and a traumatic past.
Diagnoses included “Posttraumatic stress disorder, in remission[,]” and “Seizures,
by history.” Id. at 48. A history of back, neck, and abdominal pain were also
noted, among other diagnoses.
7

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 8 of 14
Henderson appears to have had other health concerns that are not germane to this
case.
B. Health Contemporaneous to the Alleged Vaccinations on April 14
and 16, 2016
On February 20, 2016, Mr. Henderson was housed at the Racine
Correctional Institution (“RCI”). Exhibit 4 at 323. A medication supply refill
request form indicates that on that date, he was given statins, Tylenol, and Tums.
Id. He was provided Senna with Docusate (stool-softener and laxative) and
Omeprazole on March 8, 2016. Id. at 316.
The records provided indicate Mr. Henderson was transferred from the RCI
to the Waupun Correctional Institution on March 29, 2016. Exhibit 4 at 319. Mr.
Henderson submitted a HSR that day, stating on his form he was supposed to have
a check-up for intestinal bleeding and claiming he was given the wrong
medication. Exhibit 4 at 319. The following day, March 30, 2016, Mr. Henderson
requested and was provided Tylenol. Id. at 320.
On April 14, 2016, Mr. Henderson received a Tdap vaccination. Exhibit 2.4
at pdf 36-37, handwritten page 27-28). The records provided do not state in which
arm the vaccine was administered. Furthermore, the records do not state that an
influenza vaccine was administered in April of 2016.9
On April 17, 2016, Mr. Henderson requested and was provided Tums,
Tylenol, and a stool-softener / laxative. Exhibit 4 at 318.
On May 12 and 14, 2016, Mr. Henderson requested and was provided
Tylenol, along with various stomach medications. Id. at 314. A May 15, 2016
9 Among the records provided, no files indicate Mr. Henderson received a
flu vaccine. In a HSR form dated July 4, 2018, Mr. Henderson wrote: “Mark
Jensen destroyed my Vaccine file for Flu.” Exhibit 3 at 371. No further
information was provided to corroborate this allegation. This allegation seems
unlikely given the immunization registration form provided (exhibit 2.4 at pdf 37),
which lists all vaccines administered in 2016 and 2018. It lists influenza vaccine
with a recommendation date of 08/01/2017 but does not list influenza vaccine
under the list of administered vaccines.
8

Case 1:19-vv-00479-UNJ Document 53 Filed 08/24/22 Page 9 of 14
HSR indicated Mr. Henderson was on a list to see a doctor for kidney and liver
exams, intestinal bleeding, and migraines. Exhibit 4 at 312.
On June 1, 2016, Mr. Henderson was examined for ear pain. Exhibit 2.2 at
pdf 14. He was evaluated for hypertension on June 3, 2016. Id.
C. Events After June 2016
Mr. Henderson submitted a HSR form on July 15, 2016. On the form, he
wrote: “I took the Flu shot & developed the Flu.” Exhibit 4 at 303. He described
himself as exhausted and “drained.” A staff member noted Mr. Henderson’s lab
work was good, except for high cholesterol. He was referred to nursing for “flu
complaints.” Id. However, no accompanying records show Mr. Henderson
received a flu shot.
Mr. Henderson expressed concern about a medication change related to his
heartburn on July 28, 2016. Exhibit 2.2 at pdf 17. Under musculoskeletal and
neurological examinations, a staff member noted “[n]o apparent abnormalities.”
Id. at pdf 18.
On August 9, 2016, Mr. Henderson submitted a HSR form. He wrote: “I’m
having sleep fits & seizures again. My cellmate Wachoviack told Sgt. / security I
threaten to kill him at night. Security moved him. I have terrible shaking and
anxiety. I have a history of stabbing inmates & attacking staff. Reapply
prescription Tegretol, Klonopin, etc.” Exhibit 4 at 296. Mr. Henderson attached a
handwritten description of multiple “Seizures / Sleep Awake” issues that he
recalled. The self-authored report recounts sleep fits, seizures, and shaking
headaches experienced between July 19, 2016 and August 9, 2016. Id. 297.
A Nursing Encounter Progress Note from October 31, 2016 documents some
concerns. Mr. Henderson complained of ear pain. Moderate tremors when eating
and writing were documented as well as reported difficulty walking. Exhibit 2.2 at
pdf 13.
None of the records from 2017 appear relevant to Mr. Henderson’s claims.
Mr. Henderson was evaluated on September 5, 2018. Exhibit 3 at 27. He
had multiple complaints. Id. He told the treater that he had a CT scan, during
which he received an IV. Mr. Henderson reported that afterwards, he had “anterior
arm pain” but denied any further injury or trauma. Id. The treater assessed Mr.
Henderson as having right arm pain and recommended physical therapy. Id. at 28.
9

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In 2019, Mr. Henderson reported an “ongoing” right shoulder injury.
Exhibit 3 at 187-88. However, the preceding notes and HSRs do not discuss the
right shoulder injury, making it difficult to discern when the pain began. Dr.
Daniel LaVoie diagnosed Mr. Henderson with “right anterior shoulder pain” and
referred him to a physical therapist. Id. at 188.
Records exist regarding Mr. Henderson’s health in 2020 and 2021.
However, these do not bear recitation given they relate to ongoing issues unrelated
to his claims.
IV. 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
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 the 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 the dissenting judge’s contention that the special
master confused preponderance of the evidence with medical certainty).
Mr. Henderson alleges, by implication, that he suffered a Table SIRVA and
an off-Table injury.10 For an off-Table injury case, the Federal Circuit has defined
the elements of a petitioner’s case. Petitioners bear a burden “to show by
preponderant evidence that the vaccination brought about [the vaccinee’s] injury
10 The Vaccine Injury Table associates the flu vaccine with anaphylaxis, a
shoulder injury, syncope, and Guillain-Barre syndrome. XIV. Mr. Henderson has
alleged “injury of shoulder deltoid muscle and nerves, [and a] severe allergic
(anaphylaxis) seizure reaction, etc.” A seizure reaction seems to be an off-Table
claim. There are no medical records supporting an anaphylaxis or any immediate
adverse reaction to any vaccinations.
10

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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).
To find vaccine-causation, a petitioner must substantiate his case with
medical records or medical opinion. See id. at 1279 (citing 42 U.S.C. § 300aa-
13(a)(1)). Medical records are presumed to be accurate and “complete” such that
they present all relevant information on a patient's health problems. Cucuras, 993
F.2d at 1528. Additionally, “petitioners must proffer trustworthy testimony from
experts who can find support for their theories in medical literature in order to
show causation under the preponderance of the evidence standard.” LaLonde v.
Sec’y of Health & Hum. Servs., 746 F.3d 1334, 1341 (Fed. Cir. 2014).
V. Analysis
Mr. Henderson alleges he developed “injury of shoulder deltoid muscle and
nerves, [and a] severe allergic (anaphylaxis) seizure reaction, etc.” from influenza
and Tdap vaccines he allegedly received on April 14 and 16, 2016. Pet., filed Apr.
1, 2019, at pdf 2. These conditions are discussed below. Mr. Henderson does not
provide a medical theory, a logical sequence of cause and effect between the
vaccine(s) and his alleged injuries, or a timeframe in which vaccine causation
could be inferred. Therefore, Mr. Henderson does not meet any of the elements
required by Althen.
A. Injury of Shoulder Deltoid Muscle and Nerves (Table-SIRVA)
The undersigned will charitably interpret this allegation as alleging SIRVA,
a Table injury. As previously discussed, the record does not demonstrate that Mr.
Henderson received a flu vaccine. Thus, to prove he suffered a SIRVA in this
case, the shoulder injury would need to relate to the Tdap vaccine that he received
on April 14, 2016. Exhibit 2.4; exhibit 2.4 at pdf 37.11
The Vaccine Injury Table provides that SIRVA is a presumptive injury for a
Tdap vaccine when the petitioner develops shoulder pain within 48 hours of the
11 The Wisconsin Immunization Registry form provided indicates a Pertussis/Tdap and
Td vaccine were administered on April 14, 2016. The next listed immunizations are for
Hepatitis B, administered in 2018. There are no other listed vaccines between these dates. This
record tends to suggest Mr. Henderson did not receive a flu vaccine on April 14 or 16, 2016.
11

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vaccine administration, has not history of pain, inflammation or dysfunction in the
affected shoulder prior to vaccination, the pain is limited to that shoulder, and there
is no other condition that would explain the shoulder pain. See 42 C.F.R. §
100.3(a)(I)(C) and (c)(10).
One problem is the medical records do not specify which arm received the
Tdap vaccine. Similarly, the petition does not state which shoulder was allegedly
injured. These facts alone make determining the existence of a SIRVA difficult.
42 C.F.R. 100.3(a). Nonetheless, even assuming shoulder pain developed in the
arm in which the Tdap vaccine was administered, another significant issue
precludes a finding of entitlement to compensation. Namely, pain within 48 hours
of administration has not been demonstrated. The records do not show that Mr.
Henderson discussed or reported shoulder pain with a medical provided until
August of 2018. Exhibit 3 at 27-28. In the contemporaneous record, Mr.
Henderson related his arm pain to a recent IV. Without evidence that his
arm/shoulder pain developed within 48 hours of a vaccination, Mr. Henderson
cannot succeed on a Table SIRVA claim. 42 U.S.C. § 300aa-13(a)(1)(B) (the
special master may not make a finding that petitioner has demonstrated a fact by a
preponderance of the evidence “based on the claims of a petitioner alone,
unsubstantiated by medical records or by medical opinion.”).
B. Allergic Seizure Reaction and Nerve Damage (Off-Table)
To succeed in proving entitlement to compensation for off-Table injuries,
petitioners must show by preponderant evidence “a medical theory causally
connecting the vaccination to the injury.” Althen, 418 F.3d at 1278. Mr.
Henderson has not met his burden of presenting a persuasive medical theory that
the Tdap vaccine caused an allergic seizure reaction. Mr. Henderson has failed to
present any medical records that contain a causal medical theory. Mr. Henderson
has also not presented any expert reports or testimony linking the vaccine to a
seizure reaction. Consequently, Mr. Henderson has not met his burden under the
first prong of Althen.
Mr. Henderson is also required to show with preponderant evidence “a
logical sequence of cause and effect showing that the vaccination was the reason
for the injury.” Althen, 418 F.3d at 1278. The Federal Circuit has instructed
special masters to carefully consider the views of treating physicians. Capizzano
v. Sec’y of Health & Hum. Servs., 440 F.3d 1317, 1326 (Fed. Cir. 2006). Here,
statements from Mr. Henderson’s treating physicians do not support a logical
sequence of cause and effect. None of Mr. Henderson’s treating doctors and
nurses considered that he suffered a vaccine-related seizure disorder or nerve
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injury. Additionally, the records suggest Mr. Henderson was having seizures prior
to the April 2016 vaccination. Exhibit 4 at 47-48. Thus, the evidence does not
support a finding of a logical sequence of events between the vaccine and Mr.
Henderson’s alleged seizure reaction. Additionally, the evidence does not support
a finding that he experienced a nerve-related injury.
Finally, Mr. Henderson must show by preponderant evidence “a proximate
temporal relationship between vaccination and injury.” Althen, 418 F.3d at 1278.
Additionally, “[w]hen a petitioner relies upon proof of causation in fact rather than
proof of a Table Injury,” as Mr. Henderson does here, “a proximate temporal
association alone does not suffice to show a causal link between the vaccination
and the injury.” Grant v. Sec’y of Health & Hum. Servs., 956 F.2d 1144, 1148
(Fed. Cir. 1992). Although some of the records Mr. Henderson provided mention
seizures, they do not relate contemporaneously to his immunization. Even if they
did, this it is not enough to establish causation. The lack of preponderant evidence
regarding the first two Althen prongs would still prevent a finding of vaccine-
causation.
For these reasons, Mr. Henderson has not shown that he is entitled to
compensation for seizure reactions and/or nerve damage.
VI. Conclusion
The medical records provided show that Mr. Henderson has suffered various
from various problems, prior to and during his incarceration. He deserves
sympathy and compassion for the difficulties in his life. Additionally, his ability to
represent himself and to gather medical records under difficult circumstances is
admirable.
However, the medical records do not contain persuasive proof that he
suffered the claimed injuries. Mr. Henderson has not provided medical testimony
to advance his claims. Accordingly, Mr. Henderson has not demonstrated with
preponderant evidence that he is entitled to compensation.
The Clerk’s Office is instructed to enter judgment in accord with this
decision unless a motion for review is filed. For information about motions for
review, including the deadline for any motion for review, the parties may consult
the Vaccine Rules, which are found on the court’s website.
IT IS SO ORDERED.
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s/Christian J. Moran
Christian J. Moran
Special Master
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