HELLER v. HHS
OFFICE OF THE SPECIAL MASTERS
No. 96-0797V
(Filed on June 22, 1998)
CARMEN D. HELLER, Administratrix of the Estate of ISAIAH D. JONES, Petitioners,
TO BE PUBLISHED
SECRETARY OF HEALTH AND HUMAN SERVICES,
Respondent. Michael J. Kaplan, Akron, OH, for petitioner.
Linda S. Renzi, Washington, DC, for respondent.
DECISION AND ORDER
MILLMAN, Special Master
On December 20, 1996, Carmen D. Heller, on behalf of her son, Isaiah D. Jones (hereinafter
"Isaiah"), filed a petition for compensation under the National Childhood
Vaccine Injury Act of 1986(1) (hereinafter the "Vaccine Act" or the
"Act"). Petitioner has satisfied the requirements for a prima facie case
pursuant to 42 U.S.C. § 300aa-11(c) by showing that: (1) she has not previously
collected an award or settlement of a civil action for damages arising from the vaccine
injury, and (2) DPT vaccine was administered to Isaiah in the United States.
Petitioner alleges that DPT was the cause-in-fact of Isaiah's death. 42 U.S.C.
§𨶄aa-11(c)(1)(C)(ii)(I). Respondent defends by asserting that DPT did
not cause Isaiah's death.
At petitioner's counsel's request, the court rules on the records.
FACTS
Isaiah was born on January 29, 1996. Med. recs. at Ex. 1, p. 1. He received his first DPT
vaccination on April 8, 1996 when he was two and one-quarter months old.(2) Med. recs. at
Ex. 4, p.
4. Isaiah died on April 9, 1996. Med. recs. at Ex. 8, p. 1. Isaiah was taken to Children's
Hospital Medical Center of Akron on April 9, 1996 at 8:55 a.m. Med. recs. at Ex. 6, p. 2.
A history given reflects that Isaiah's formula was switched to Isomil on April 8, 1996
because he had vomiting associated with the use of Enfamil. Id. He had received his first
set of immunizations on April 8, 1996. Id. The record further reflects that, on April 9,
1996, Ms. Heller gave Isaiah a bottle at 1:00 a.m. Id. Thereafter, she put him to sleep.
Id. When Ms. Heller found Isaiah at 7:30 a.m., he was not breathing. Id. She called the
Akron Fire Department which noted that Isaiah was apneic, and pulseless with rigor
mortis/livid reticular. Id. They decided not to proceed with CPR. Id. There was no
evidence of trauma on Isaiah's scalp. Id The hospital questioned whether he died from SIDS. Id.
The initial death certificate states that the cause of Isaiah's death was
"pending." Med. recs. at Ex. 8, p. 1. However, a supplementary medical
certification dated May 6, 1996 reflects that the cause of death was SIDS. Med. recs. at
Ex. 8, p. 3. The autopsy, which was performed on April 9, 1996, also diagnosed SIDS. Med.
recs. at Ex. 9, p. 1. The autopsy further reflects that Isaiah had petechiae in his lung,
thymus, and heart. Id. On gross description, his thymus weighed thirty grams which is very
heavy for a two to three month old infant. Med. recs. at Ex. 9, p. 4. The surface of his
thymus was covered with multiple, minute petechiae. Id. There was no evidence of
inflammation or aspiration. Med. recs. at Ex. 9, p. 6. On microscopic examination, the
section through the spleen showed congestion of the red pulp. Med. recs. at Ex. 9, p. 7.
The clinical summary states that Isaiah was placed face down on a sheet when put to bed.
Med. recs. at Ex. 9,
AFFIDAVITS
Ms. Heller submitted an affidavit, dated November 15, 1996, which states that Isaiah was
vaccinated on April 8, 1996 between 9:00 and 10:00 a.m. Med. recs. at Ex. 7, p. 1. When
she found Isaiah on April 9, 1996 at 7:30 a.m., he was not breathing. Id.
Petitioner's counsel posed a series of questions to Ms. Heller regarding Isaiah's
post-vaccination condition. Ms. Heller answered these questions in a handwritten
supplemental affidavit.
P. Supp. Aff. (filed March 12, 1998). In this affidavit, Ms. Heller said that Isaiah cried
or screamed "a little off and on" after his vaccination. Id. He also slept more
than usual. Id. Ms. Heller stated that Isaiah was a little pale; however, she was not
impressed by his coloring. Id. She further noted that he threw up more than usual, was
unresponsive, and had a slight fever after his DPT. Id. Prior to his vaccination, he was
very playful and happy. Id. After the vaccination, however, he was quiet, slept, and
cried. Id. Ms. Heller's acquaintances asked her why Isaiah slept for such long periods of
time. Id. When she found Isaiah dead, there was blood on the sheets and around his mouth.
Id.
MEDICAL EXPERT REPORTS
Petitioner submitted the medical export report of Dr. A. Hugh McLaughlin, D.O.,(3)
Isaiah's doctor. Dr. McLaughlin's opinion is that, since there was no evidence to suggest
a cause of death other than vaccination, the vaccinations caused Isaiah's death.(4) Med.
recs. at Ex. 10, p. 1.
Dr. McLaughlin submitted a supplemental report which states that the direct cause of
Isaiah's death was SIDS involving both anaphylaxis and encephalopathy. P. Supp. Rprt.
(filed January 23, 1998). Dr. McLaughlin noted that although the exact cause of SIDS is
unknown, the vaccine has been shown to be causally related. Id. For that reason, it is
probable that the vaccine could have caused Isaiah's death. Id.
Petitioner also submitted medical articles in support of Dr. McLaughlin's opinion. The
first article discusses a study in which the authors found a 7.3 elevation in risk for
SIDS in the first four days after DPT immunization during the first year of life.(5)
Children who were not immunized had a SIDS mortality rate more than six times higher than
those who had been immunized.(6) The authors of the article admitted, however, that the
relatively small number of SIDS cases in the present study
permitted the possibility of substantial random error. (7)
Petitioner submitted a second article which discussed a Tennessee study conducted to
determine if there were a meaningful association between DPT and four, sudden unexplained
deaths.(8) The authors found no evidence to indicate a causal relationship between DPT and
SIDS.(9) The overall incidence of SIDS did not increase in Tennessee during the time
period that the suspect lot of DPT was used.(10) Age distribution curves of SIDS cases in
Europe where vaccination schedules differ from the United States are similar to the United
States curve of SIDS cases, thereby indicating no association between DPT and SIDS.(11)
The Centers for Disease Control reviewed the available evidence in the study, and
concluded that no causal relationship had been established between DPT and SIDS.(12) In
addition, a National Institutes of Health case control study failed to show any increased
frequency of DPT vaccinations in SIDS.(13)
Finally, petitioner submitted a paragraph summarizing a speech given by William C. Torch
at a child neurology conference.(14) This speech discussed a study on the relationship
between DPT and SIDS.(15) Torch concluded that DPT may be a generally unrecognized major
cause of SIDS.(16) Respondent submitted the expert medical report of Dr. M. Louis
Offen. R. Ex. A. He
concluded that Isaiah died from SIDS. R. Ex. A, p. 2. In Dr. Offen's opinion, Isaiah did
not have encephalopathy or anaphylaxis. Id. Dr. Offen stated that a maternal history of
smoking, such as Ms. Heller had, as well as placing an infant lying down to sleep in the
prone position puts a child at an increased risk of SIDS. R. Ex. A, pp. 1-2.
DISCUSSION
The Vaccine Act affords petitioner three distinct theories of recovery, thereby allowing
causation to be proven by showing that: (1) a Table injury occurred as a result of the
vaccine, (2) a pre-existing condition was significantly aggravated by the vaccine, or (3)
the vaccine was the cause-in-fact of the injury. Section 14(a) contains the Vaccine Injury
Table (hereinafter "Table").(17) If any of the various injuries in this Table
occurs within the statutorily defined time period, a rebuttable presumption of causation
has been proven. To rebut this presumption, respondent must provide affirmative evidence
demonstrating that a known factor unrelated was the cause-in-fact of the petitioner's
condition.(18)
Since the promulgation of the Act, the Table has been altered through a change in the
regulations, making it more difficult to prove a Table encephalopathy.(19) The
requirements for proving anaphylaxis have similarly become more difficult.(20) Since
petitioner filed her petitioner after the effective date of these regulations, the more
restrictive standards apply to her claims.
Although petitioner initially began with the assertion that DPT was the cause-in-fact of
Isaiah's death, Dr. McLaughlin's supplemental report opines that Isaiah died from SIDS
accompanied by encephalopathy and anaphylaxis. Before addressing petitioner's
cause-in-fact claim, Dr. McLaughlin's reference to encephalopathy and anaphylaxis merit
some comment. Timing and symptomatology are critical to whether petitioner has proven that
a Table injury has occurred. In order to prevail on a Table theory, the injury must have
occurred within the statutory time period. Once it is determined that timing is
appropriate, the undersigned will evaluate the symptoms that petitioner exhibited. Using
the definitions and interpretive aids set forth in the Act, the undersigned will then
determine if the symptoms that petitioner experienced were sufficient to demonstrate that
a Table injury occurred. Under the Act, the onset of anaphylaxis must occur within four
hours of vaccination for petitioner to prevail on a Table injury theory. Isaiah did not
suffer an on-Table anaphylaxis, as Dr. McLaughlin suggests, because he did not have a
systemic allergic response within four hours of vaccination.
Since Isaiah died within seventy-two hours of vaccination, petitioner can, however,
attempt to prove symptoms of an on-Table encephalopathy. But, Isaiah's symptomatology does
not reflect twenty-four hours of significantly decreased level of consciousness. When
Isaiah was brought to the hospital, Ms. Heller gave a history that she fed Isaiah at 1:00
a.m. that morning and then put him to sleep. There is no history that Isaiah failed to
respond to the feeding or that he had any symptoms that would indicate abnormality.
Following the strict language of the new regulations, the undersigned cannot hold that
Isaiah's symptoms the day after vaccination rise to the level of a Table encephalopathy.
There is no doubt that Isaiah was dying after his vaccination. He manifested symptoms of a
decreased level of consciousness that would merit a diagnosis of encephalopathy and he was
undergoing a systemic process that was severe as is anaphylaxis. However, these
manifestations were due to the agonal process. In other words, these symptoms were a
consequence of dying rather than of vaccination. This conclusion is evidenced by the fact
that Dr. McLaughlin did not mention that Isaiah suffered any of these symptoms prior to
his death. Rather, he stated that anaphylaxis and encephalopathy accompanied Isaiah's
death which he termed due to SIDS.
Death, in and of itself, is not a Table injury. Hodges v. Secretary, HHS, 9 F.3d 958 (Fed.
Cir. 1993), and Hellebrand v. Secretary, HHS, 999 F.2d 1565 (Fed. Cir. 1993). In order for
petitioner to prevail upon a Table injury theory, the injury must precede the death and
not merely be a consequence of the dying process. Petitioner herein has failed to show the
existence of a Table injury, thereby leaving the original claim that DPT was the
cause-in-fact of Isaiah's death.
To satisfy her burden of proving causation in fact, petitioner must offer "proof of a
logical sequence of cause and effect showing that the vaccination was the reason for the
injury. A reputable medical or scientific explanation must support this logical sequence
of cause and effect." Grant v. Secretary, HHS, 956 F.2d 1144, 1148 (Fed. Cir. 1992).
Agarwsal v. Secretary, HHS, 33 Fed. Cl. 482, 487 (1995); see also Knudsen v. Secretary,
HHS, 35 F.3d 543, 548 (Fed. Cir. 1994); Daubert v. Merrell Dow Pharmaceuticals, Inc., 509
U.S. 579 (1993). "[E]vidence showing an absence of other causes does not meet
petitioners' affirmative duty to show actual or legal causation." Grant, supra, 956
F.2d at 1149.
Dr. McLaughlin's initial affidavit states that since he could find no cause for Isaiah's
death other than the vaccinations, the vaccinations must have caused his death. Pursuant
to Grant, supra, this is legally insufficient to prove affirmatively that DPT caused
Isaiah's death. Petitioner does not satisfy her burden by showing that no other cause for
the death is known.
Moreover, reliance on temporality alone is legally insufficient even though the death
followed the vaccination by one day. Strother v. Secretary, HHS, 950 F.2d 731 (Fed. Cir.
1991). That B follows A does not prove by that fact alone that A caused B.
Dr. McLaughlin's supplemental report states that, although no one knows the cause of SIDS,
he thinks it probable that DPT could have caused Isaiah's SIDS. Beyond being a sentence
that contradicts itself , i.e., "probable" does not agree with
"could," Dr. McLaughlin's thesis is not supported by the articles petitioner
submitted. These articles do not confirm that DPT causes a higher incidence of SIDS among
vaccinees as compared to non-vaccinees. Unfortunately, no one knows the cause of SIDS. The
suggestion by Dr. Torch in his presentation is squarely opposed in an article on the same
subject. There is no support for Dr. McLaughlin's thesis other than his musing on the
possibility. In addition, his curriculum vitae is rather short on medical or scientific
accomplishment, bearing on his credibility as a witness. The undersigned does not recall
seeing a prior curriculum vitae of an expert in which he prominently lists doing a
commercial for McDonald's. This type of background is not conducive to developing a sense
of credibility in the witness.
Although respondent does not have the burden to prove what caused Isaiah's death,
respondent's expert opined that this was a true case of SIDS. The autopsy report and the
death certificate reach the same conclusion.
This is indeed a tragic case. Not only is Isaiah dead, but the cause of his death remains
a mystery. It is unfortunate that the court cannot provide an answer for Mrs. Heller;
however, the undersigned can only analyze the medical evidence and reports to determine
whether the petitioner has met her burden of proving that DPT caused in fact Isaiah's
death. The court finds that petitioner has not met her burden. She has not provided
persuasive evidence in Dr. McLaughlin's reports that herein is a "logical sequence of
cause and effect." Grant, supra, at 1148.
CONCLUSION
This petition is dismissed with prejudice. In the absence of a motion for review filed
pursuant to RCFC Appendix J, the clerk of the court is directed to enter judgment in
accordance herewith.
IT IS SO ORDERED.
Laura D. Millman
Special Master
1. The National Vaccine Injury Compensation Program comprises Part 2 of the National
Childhood Vaccine Injury Act of 1986, 42 U.S.C.A. 𨶄aa-1 et seq. (West 1991), as
amended by Title II of the Health Information, Health Promotion, and Vaccine Injury
Compensation Amendments of November 26, 1991 (105 Stat. 1102). For convenience, further
references will be to the relevant subsection of 42 U.S.C.A. § 300aa.
2. Isaiah also received his polio and hemophilus B influenza vaccinations at this time.
Med. recs. at Ex. 4, p. 4.
3. Dr. McLaughlin's curriculum vitae includes a national television commercial for
McDonald's Corporation in 1985 with an article in Time Magazine related to that commercial
in the same year.
4. This report takes the form of an affidavit.
5. Walker, A.M., et al.,"Diphtheria-Tetanus-Pertussis Immunization and Sudden Infant
Death Syndrome," 77 Amer. J. of Public Health 945, 947 (1987) (filed February 23,
1998).
6. Id. at 947.
7. Id. at 948.
8. Bernier, R.H., et al.,"Diphtheria-tetanus toxoids-pertussis vaccination and sudden
infant deaths in Tennessee," 101 Clinical and Laboratory Observations 419 (1982)
(filed February 23, 1998).
9. Id. at 421.
10. Id.
11. Id.
12. Id.
13. Id.
14. See Torch, William, C., "Diphtheria-Pertussis-Tetanus (DPT) Immunization
Potential Cause of the Sudden Infant Death Syndrome (SIDS)," 32 Neurology A169 (1982)
(filed February 23, 1998).
15. Id.
16. Id. at A170.
17. 42 U.S.C. § 300aa-14(a).
18. 42 U.S.C § 13(a)(1)(B).
19. 42 C.F.R. 𨲼.3(b)(2)(I)(A) (see also Fed. Reg. 60, No. 26 at 7694-96 (Feb.
8,1995), effective March 10, 1995). This section states that "an acute encephalopathy
is indicated by a significantly decreased level of consciousness lasting for at least 24
hours." Id. Subsection (D) provides:"[a] 'significantly decreased level of
consciousness' is indicated by the presence of at least one of the following clinical
signs for at least 24 hours or greater...: (1) Decreased or absent response to environment
(responds, if at all, only to loud voice or painful stimuli); (2) Decreased or absent eye
contact (does not fix gaze upon family members or other individuals); or (3) Inconsistent
or absent responses to external stimuli (does not recognize familiar people or
things)." Subsection (E) provides:
"The following clinical features alone, or in combination, do not demonstrate an
acute encephalopathy or a significant change in either mental status or level of
consciousness as described above: Sleepiness, irritability (fussiness), high-pitched and
unusual screaming, persistent inconsolable crying, and bulging fontanelle."
20. 42 C.F.R. 𨲼.3(b)(1) (see also Fed. Reg. 60, No. 26 at 7694 (Feb. 8, 1995))
Under this section, anaphylaxis is defined as: "an acute, severe, and potentially
lethal systemic allergic reaction.. . Signs and symptoms begin minutes to a few hours
after exposure. Death, if it occurs, usually results from airway obstruction caused by
laryngeal edema or bronchospasm and may be associated with cardiovascular
collapse...."