Court Opinion

ID: 3009059
Source: CourtListenerOpinion
Date Created: 2015-10-09 16:02:22.682568+00
Date Added: 2024-06-11T11:46:15.268361
License: Public Domain

In the United States Court of Federal Claims
                                 OFFICE OF SPECIAL MASTERS
                                            No. 15-466V
                                     Filed: September 18, 2015
                                         Not to be Published

*************************************
SHOLOM WOLMAN and YONIT                    *
WOLMAN in their own right and              *
as best friends of their son SDW,          *
                                           *
                Petitioners,               *     Petitioner’s motion for a ruling
                                           *     on the record granted; no expert
 v.                                        *     report to prove significant
                                           *     aggravation of esophagitis;
SECRETARY OF HEALTH                        *     medical records do not support.
AND HUMAN SERVICES,                        *
                                           *
                Respondent.                *
                                           *
*************************************
John F. McHugh, New York, NY, for petitioners.
Christine M. Becer, Washington, DC, for respondent.

MILLMAN, Special Master

                                               DECISION 1

       On May 7, 2015, petitioners filed a petition under the National Childhood Vaccine Injury
Act, 42 U.S.C. § 300aa-10-34 (2012), alleging that haemophilus B influenza (“HiB”), measles-
mumps-rubella (“MMR”), pneumococcal (“Prevnar”), and chickenpox (“Varicella”) vaccines
administered on June 11, 2012 significantly aggravated their son SDW’s pre-existing
esophagitis.

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  Because this decision contains a reasoned explanation for the special master’s action in this case, the
special master intends to post this decision on the United States Court of Federal Claims’ website, in
accordance with the E-Government Act of 2002, Pub. L. No. 107-347, 116 Stat. 2899, 2913 (Dec. 17,
2002). Vaccine Rule 18(b) states that all decisions of the special masters will be made available to the
public unless they contain trade secrets or commercial or financial information that is privileged and
confidential, or medical or similar information whose disclosure would constitute a clearly unwarranted
invasion of privacy. When such a decision is filed, petitioners have 14 days to identify and move to
redact such information prior to the document’s disclosure. If the special master, upon review, agrees that
the identified material fits within the categories listed above, the special master shall redact such material
from public access.
        The undersigned, having reviewed the medical records, finds they do not support
petitioners’ allegations. The medical records substantiate that SDW had been throwing up daily
since he was four months old and do not indicate any significant worsening eight months later
when he received the allegedly-causative vaccinations. The undersigned cannot rule in
petitioners’ favor based solely on their allegations unsupported by medical records or medical
opinion. 42 U.S.C. § 300aa-11(a)(1). Petitioners have not filed a medical expert opinion in
support of their allegations.

       The Vaccine Act defines “significant aggravation” as follows: “The term ‘significant
aggravation’ means any change for the worse in a preexisting condition which results in
markedly greater disability, pain, or illness accompanied by substantial deterioration of health.”
42 U.S.C. § 300aa-33(4).

        On September 18, 2015, petitioners filed a Status Report requesting the undersigned issue
a decision on the record as it stands. The undersigned interprets this Status Report as a motion
for a ruling on the record. Since, no medical records support significant aggravation of SDW’s
pre-existing gastritis and petitioners have not filed an expert medical report supporting their
allegations, the undersigned dismisses this case.

       The undersigned GRANTS petitioners’ motion and DISMISSES this case. The
telephonic status conference previously set for October 29, 2015 is hereby cancelled.

                                             FACTS

                             Pre-June 11, 2012 vaccination records

       SDW was born on June 9, 2011.

        On August 24, 2011, he received DTaP (“diphtheria-tetanus-acellular pertussis”),
hepatitis B, HiB, IPV (“inactivated polio vaccine”), and Prevnar vaccinations. Med. recs. Ex. 4,
at 64.

       On October 26, 2011, he received DTaP, hepatitis B, HiB, IPV, and Prevnar vaccinations.
Id. On November 2, 2011, he was diagnosed with atopic dermatitis. On December 15, 2011, he
was diagnosed with eczema.

       On December 28, 2011, he received DTaP, HiB, IPV, Prevnar, and rotavirus (“Rotateq”)
vaccinations. Id.

        On January 5, 2012, SDW saw Dr. Mary Georgy, an allergist and immunologist. Med.
recs. Ex. 5, at 38. SDW had a rash which started when he was four to five months old. Id. His
family history included a grandmother and his father who have eczema. Id. He lived in a
basement with a musty smell. Id. at 39. Her diagnosis was likely atopic dermatitis. Id. Food

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was likely contributing to its severity. Id. The source was likely from SDW’s mother’s diet. Id.
Dr. Georgy told SDW’s mother to avoid eggs and milk. Id. SDW was to avoid soy and cow’s
milk. Id.

       On March 28, 2012, he received hepatitis B vaccine. Id.

       On June 11, 2012, he received HiB, MMR, Prevnar and Varicella vaccinations. Id.

                           Post-June 11, 2012 vaccination records

        On July 8, 2012, SDW was vomiting on and off for two months and was allergic to eggs,
milk, soy, nuts, and sesame. Med. recs. Ex. 8, at 39.

      On July 12, 2012, SDW visited his pediatrician’s office and saw medical assistant Feiga
Berenbaum, who noted SDW had no known problems. Id. at 28. He was allergic to egg, milk,
soybean, sesame, and dust. Id.

        On September 27, 2012, SDW received DTaP and hepatitis A vaccinations. Med. recs.
Ex. 4, at 64, and Ex. 8, at 25.

       On March 13, 2012, SDW saw Dr. Jonathan Spergel, Allergy Section Chief, at Children’s
Hospital of Philadelphia. Med. recs. Ex. 8 at 30. SDW had eczema, food allergies, and
vomiting. Id. SDW had had eczema since he was four months of age affecting his entire body.
Id. The eczema had improved over time. Id. Currently, the eczema was mainly on his face. Id.
Triggers of eczema included viral infections. Id. His face broke out with spinach, broccoli, and
tuna. Id. He was currently on a gluten-free diet. Id. He vomited after soy. Id. The family tried
various alternative therapies including avoiding nightshade foods and gluten without any medical
evidence to support it. Id. at 31. Also, the family was going to a chiropractor for SDW’s
eczema. Id. Dr. Spergel diagnosed SDW with GERD (“gastroesophageal reflux disease”). Id.
He prescribed Zantac and suggested SDW obtain an upper gastrointestinal evaluation. Id.

        On March 18, 2013, SDW saw Dr. Marcos Alfie, a pediatric gastroenterologist. Med.
recs. Ex. 3, at 12. SDW had a several month history of gastroesophageal reflux (“GER”) plus
eczema. Id. His mother said SDW had been having issues with vomiting every day and with
regurgitation since he was about four months old. Id. He had eczema on his head, trunk, and
extremities. Id. He had poor weight gain over the last several months. Id. His vomit always
contained food in it with gastric secretions. Id. Skin testing found that he was allergic to soy,
peanut, milk, and beef. Id. SDW had a family history of GER and irritable bowel syndrome. Id.
at 14. Dr. Alfie diagnosed SDW with gastrointestinal symptoms stemming from partially treated
food allergies. Id.

                                         DISCUSSION

       To satisfy their burden of proving causation in fact, petitioners must prove by

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preponderant evidence: “(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 HHS 418 F.3d 1274, 1278 (Fed. Cir. 2005). In Althen, the Federal Circuit
quoted its opinion in Grant v. Secretary of Health and Human Services, 956 F.2d 1144, 1148
(Fed. Cir. 1992):

                    A persuasive medical theory is demonstrated by “proof of a logical
                    sequence of cause of and effect showing that the vaccination was
                    the reason for the injury [,]” the logical sequence being supported
                    by a “reputable medical or scientific explanation[,]” i.e., “evidence
                    in the form of scientific studies or expert medical testimony[.]”
418 F.3d at 1278.

       Without more, “evidence showing an absence of other causes does not meet petitioners’
affirmative duty to show actual or legal causation.” Grant, 956 F.2d at 1149. Mere temporal
association is not sufficient to prove causation in fact. Id. at 1148.

        Petitioners must show not only that but for SDW’s June 11, 2012 vaccinations, he would
not have had significantly aggravated gastritis, and that these vaccinations were a substantial
factor in significantly aggravating his gastritis, but also that his gastritis was significantly worse
after his June 11, 2012 vaccinations than it was before those vaccinations. Shyface v. Sec’y of
HHS 165 F.3d 1344, 1352 (Fed. Cir. 1999). The undersigned notes that SDW has been vomiting
daily since he was four months of age and the June 11, 2012 vaccinations occurred when he was
one year old. The medical records do not indicate any significant aggravation, i.e., “any change
for the worse in a preexisting condition which results in markedly greater disability, pain, or
illness accompanied by substantial deterioration of health.” 42 U.S.C. § § 300aa-33(4).

        The Vaccine Act does not permit the undersigned to rule for petitioners based on their
claims alone, “unsubstantiated by medical records or by medical opinion.” 42 U.S.C. § 300aa-
13(a)(1). In the instant action, none of SDW’s medical records substantiate petitioners’ claim of
significant aggravation. Moreover, petitioners have not filed an expert medical opinion
substantiating their claims.

       The undersigned GRANTS petitioners’ motion for a ruling on the record and
DISMISSES this case for petitioners’ failure to prove by a preponderance of the evidence the
matters required in the petition. 42 U.S.C. § 300aa-13(a)(1).

                                                   CONCLUSION

      This petition is DISMISSED. In the absence of a motion for review filed pursuant to
RCFC, Appendix B, the clerk of the court is directed to enter judgment herewith. 2

2
    Pursuant to Vaccine Rule 11(b), entry of judgment can be expedited by each party, either jointly or separately,
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IT IS SO ORDERED.

Dated: September 18, 2015                                  /s/ Laura D. Millman
                                                             Laura D. Millman
                                                               Special Master

filing a notice renouncing the right to seek review.
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