     In the United States Court of Federal Claims
                               OFFICE OF SPECIAL MASTERS
                                     Filed: April 7, 2016

* * * * * * * * * * * * * *               *               PUBLISHED
ERICA FESTER, parent of                    *
B.A.B., a minor,                           *
                                           *              No. 10-243V
              Petitioner,                  *
                                           *
v.                                         *              Chief Special Master Dorsey
                                           *
                                           *              Proquad (“MMRV”) Vaccine;
SECRETARY OF HEALTH                        *              Autism (“ASD”); Encephalopathy;
AND HUMAN SERVICES,                        *              Subacute Encephalopathy;
                                           *              Subclinical Encephalopathy;
              Respondent.                  *              Insufficient Proof.
                                           *
 * * * * * * * * * * * * * * *
Peter Joseph Sarda, Creech Law Firm, Raleigh, NC, for petitioner.
Voris Edward Johnson, U.S. Department of Justice, Washington, D.C., for respondent.

           DECISION ON PETITIONER’S MOTION FOR RULING ON THE RECORD1

      I.      Introduction

        On April 15, 2010, Erica Fester (“petitioner”), parent of B.A.B., a minor, filed a petition
for compensation under the National Vaccine Injury Compensation Program (“the Program”),2
alleging that the combined measles, mumps, rubella, and varicella (“MMRV” or “Proquad”)
vaccine3 that B.A.B. received on April 18, 2007, caused him to suffer encephalopathy. Petition

1
  Because this decision contains a reasoned explanation for the undersigned’s action in this case,
the undersigned intends to post this ruling on the website of the United States Court of Federal
Claims, in accordance with the E-Government Act of 2002, 44 U.S.C. § 3501 note
(2012)(Federal Management and Promotion of Electronic Government Services). As provided
by Vaccine Rule 18(b), each party has 14 days within which to request redaction “of any
information furnished by that party: (1) that is a trade secret or commercial or financial in
substance and is privileged or confidential; or (2) that includes medical files or similar files, the
disclosure of which would constitute a clearly unwarranted invasion of privacy.” Vaccine Rule
18(b).
2
 The Program comprises Part 2 of the National Childhood Vaccine Injury Act of 1986, 42
U.S.C. §§ 300aa-10 et seq. (hereinafter “Vaccine Act” or “the Act”). Hereafter, individual
section references will be to 42 U.S.C. § 300aa of the Act.
3
    B.A.B. received one dose of the vaccine Proquad, which contains the measles, mumps, rubella,
                                                 1
at ¶ 5. Petitioner contends that B.A.B.’s “loss of prior skills and his current developmental delay
is [sic] the sequela of that brain injury.” Id. The medical records and other information in the
record, however, do not support a finding that petitioner is entitled to compensation.

        Under the Program, petitioner may not receive compensation based solely upon her
claims, as the petition must be supported by either medical records or by the opinion of a
qualified physician proving a causal relationship. See § 13(a)(1). Here, the medical records do
not support petitioner’s claims, so a medical opinion is required. Petitioner has offered the
opinion of Dr. Karen Harum.4 However, Dr. Harum’s opinion fails to provide support for the
elements necessary to prove causation.

        For these reasons, and the reasons discussed below, petitioner has failed to demonstrate
that she is entitled to compensation.

    I.     Procedural History

      Petitioner filed her case pro se on April 15, 2010. In support of her claim, petitioner filed
medical records labeled as exhibits 1-12. Approximately three months later, she filed additional
medical records and videotapes. See Pet’r’s Exs. 16-17 filed Aug. 19, 2010 (ECF Nos. 10).5

        On September 10, 2010, respondent filed her Rule 4(c) Report, stating that the case was
not appropriate for compensation. Petitioner filed a response to the Rule 4(c) Report on
February 8, 2011. Although petitioner argued that three of B.A.B.’s treating doctors believed
B.A.B. suffered an encephalopathy and two believed that B.A.B. “had received a vaccine
injury,” she agreed that she needed the report of a medical expert to support her claim. Pet’r’s
Response to Respondent’s Rule 4(c) Report at 3-4 (ECF No. 20).6

       Because B.A.B. was diagnosed with autism by at least one treating doctor, the case was
reassigned, over petitioner’s objection,7 to former Chief Special Master Vowell, one of the

and varicella vaccines. Petitioner’s Exhibits (“Pet’r’s Exs.”) 3 at 2-3; 6 at 15.
4
 See Pet’r’s Exs. 19, 26, 29 (initial and two supplemental reports). Dr. Harum is a
neurodevelopmental pediatrician who began treating B.A.B. in September 2008. See
Respondent’s Exhibit (“Resp’s Ex.”) A at 1 (ECF No. 27) (medical records from Dr. Harum).
Because the documents submitted as Ex. A were not electronically filed and do not have ECF
numbers, the undersigned refers to the handwritten page numbers on the bottom of the document.
5
 Exhibit 16 is comprised of several photographs and movies of B.A.B as a young child. Exhibit
17 is a video clip of B.A.B. saying, “I love you.”
6
 The pages of Petitioner’s Response to Respondent’s Rule 4(c) Report are unnumbered, but this
quotation appears on the bottom of the third and the top of the fourth pages of the document.
7
 See Motion dated Feb. 23, 2011 (ECF No. 18). See also Order dated Feb. 28, 2011 (ECF No.
19).

                                                  2
special masters involved in the Omnibus Autism Proceeding (“OAP”).8 During this time,
petitioner continued to file medical records. See Pet’r’s Ex. 18 filed Apr. 14, 2011. Because
petitioner experienced difficulty obtaining the medical records from Dr. Harum, one of B.A.B.’s
treating physicians, respondent was authorized to issue a subpoena and then obtained and filed
Dr. Harum’s records on June 17, 2011. See Resp’s Ex. A; Order dated July 14, 2010 (ECF No.
9).

       After Dr. Harum agreed to provide an expert report, petitioner made numerous filings
supporting a request for advance payment of her fees. On January 26, 2012, petitioner filed
additional medical records. See Pet’r’s Exs. 20a-20d.9 On August 27, 2013, a decision was
entered denying petitioner’s request for interim advanced costs for expert fees. Decision dated
Aug. 27, 2013 (ECF No. 46).



8
 The OAP was created to manage more than 5,400 petitions alleging that autism or autism
spectrum disorder (“ASD”) was caused by either the measles, mumps, and rubella (“MMR”)
vaccine or thimerosal, an ethylmercury preservative used in multi-dose vials of vaccines. See
Autism General Order #1, dated July 3, 2002 (found at 2002 WL 31696785, 2002 U.S. Claims
LEXIS 365; also available at
http://www.uscfc.uscourts.gov/sites/default/files/autism/Autism+General+Order1.pdf (last
visited on February 16, 2016)). Three special masters conducted separate proceedings in test
cases involving the two theories of autism causation mentioned above. All found petitioners had
not provided preponderant evidence of causation, indicating the cases were “not a close case.”
King v. Sec’y of Health & Human Servs., No. 03-584V, 2010 WL 892296, at *90 (Fed. Cl. Spec.
Mstr. Mar. 12, 2010) (emphasis removed).

All three decisions were affirmed on appeal. Two of the three decisions in the Theory 1 test
cases were appealed to the Federal Circuit. Cedillo v. Sec’y of Health & Human Servs., No. 98-
916v, 2009 WL 331968 (Fed. Cl. Spec. Mstr. Feb. 12, 2009), aff’d 89 Fed. Cl. 158 (2009), aff’d,
617 F.3d 1328 (Fed. Cir. 2010); Hazelhurst v. Sec’y of Health & Human Servs., No. 03-654v,
2009 WL 332306 (Fed. Cl. Spec. Mstr. Feb. 12, 2009), aff’d, 88 Fed. Cl. 473 (2009), aff’d, 604
F.3d 1343 (Fed. Cir. 2010). Petitioners in the third test case did not appeal the Court of Federal
Claims’ decision. Snyder v. Sec’y of Health & Human Servs., No. 01-162v, 2009 WL 332044
(Fed. Cl. Spec. Mstr. Feb. 12, 2009), aff’d, 88 Fed. Cl. 706 (2009). Petitioners did not seek
review of the special masters’ decisions in the Theory 2 test cases. Dwyer v. Sec’y of Health &
Human Servs., No. 02-1202v, 2010 WL 892250 (Fed. Cl. Spec. Mstr. Mar. 12, 2010); King v.
Sec’y of Health & Human Servs., No. 03-584v, 2010 WL 892296 (Fed. Cl. Spec. Mstr. March
12, 2010); Mead v. Sec’y of Health & Human Servs., No. 03-215v, 2010 WL 892248 (Fed. Cl.
Spec. Mstr. March 12, 2010). For further information and a comprehensive discussion of the
OAP and proceedings after the conclusion of the test case litigation, see Sturdivant v. Sec’y of
Health & Human Servs., No. 07-788, 2016 WL 552529 (Fed. Cl. Spec. Mstr. Jan 21, 2016).
9
  Although there is a later filed exhibit also labeled as exhibit 20, the undersigned will continue
to use the exhibit numbers 20a-20d for the medical records filed on January 26, 2012, and exhibit
number 20 for the later filed record. See Pet’r’s Ex. 20 filed Sept. 23, 2014 (ECF No. 64).

                                                3
         Petitioner obtained counsel on April 17, 2014, and has since been represented by Mr.
Peter Sarda. On September 23, 2014, petitioner filed Dr. Harum’s expert report, curriculum
vitae (“CV”), and medical literature. See Pet’r’s Exs. 19-25 (ECF Nos. 63-64). Respondent
filed a responsive expert report, CV, and medical literature from Dr. Gregory Holmes on
December 17, 2014. See Resp’s Exs. B-P (ECF No. 66). After Special Master Vowell raised
specific criticisms of Dr. Harum’s initial expert report,10 petitioner filed the first supplemental
report from Dr. Harum on March 9, 2015. See Pet’r’s Ex. 26 (ECF No. 73). Petitioner also filed
six of the references cited by Dr. Harum as one exhibit.11 The case was reassigned to the
undersigned on February 5, 2015.

         On March 26, 2015, the undersigned held a status conference to discuss the current status
of the case. Petitioner’s counsel stated that he had been counsel of record in this case for less
than one year. Although he admitted that Dr. Harum’s report had, in certain parts, characterized
this as an autism case, he reiterated petitioner’s early arguments that her theory of causation
involves encephalopathy as the injury, not autism. Order dated Mar. 30, 2015, at 1 (ECF No.
76). Counsel for respondent stated that as long as petitioner’s expert characterized the child’s
injury as one that falls on the autism spectrum, the case could not be informally resolved. Id.

        The undersigned then inquired about the status of testing results and medical records
from the University of North Carolina (“UNC”), where B.A.B. was evaluated and underwent
genetic testing. Order dated Mar. 30, 2015, at 1 (ECF No. 76). Specifically, when B.A.B. was
seen at UNC, a report from Dr. Doreswamy questioned whether he had developmental
impairment associated with a CIAS-1 mutation, with an incomplete clinical expression of
neonatal onset multisystem inflammatory disease (“NOMID”).12 See Pet’r’s Ex. 12 at 8-9. Dr.
Doreswamy wrote, “Since the range of clinical CIAS-1 expression is broad, I will likely

10
     See Order dated Jan. 9, 2015 (ECF No. 68).
11
  See Amended Notice dated Mar. 10, 2015 (ECF No. 75) (providing the list of articles
comprising Pet’r’s Ex. 27 filed by CD on Mar. 11, 2015). Two of these articles were incomplete,
containing only the first few pages, but petitioner re-filed the complete articles approximately
three months later as Exhibit 28. See Notice dated June 8, 2015 (ECF No. 83) (providing the list
of articles comprising Pet’r’s Ex. 28, which was filed by CD on June 12, 2015.) It should be
noted that petitioner filed multiple articles as one exhibit in both exhibits 27 and 28. The
undersigned thus refers to all of these articles with the exhibit number to which petitioner
assigned them, and the ECF page numbers have been provided for ease of reference.
12
   NOMID is a “very rare” disorder, which “causes persistent inflammation and tissue damage
primarily affecting the nervous system, skin, and joints.”
https://ghr.nlm.nih.gov/condition/neonatal-onset-multisystem-inflammatory-disease (last visited
Mar. 11, 2016). Individuals with the disorder have “a skin rash that is usually present from
birth” and joint and skeletal abnormalities. Id. They “often have headaches, seizures, and
vomiting resulting from chronic meningitis, which is inflammation of the tissue that covers and
protects the brain and spinal cord (meninges).” Id. They may experience “[r]ecurrent episodes
of mild fever,” “[i]ntellectual disabilities,” “[h]earing and vision problems,” and “progressive
kidney damage.” Id.

                                                  4
advocate obtaining genetic analysis.” Id. at 8-9. Petitioner was ordered to advise whether the
testing was done, and if so, she was ordered to obtain and file the results. Order dated Mar. 30,
2015 at 1 (ECF No. 76). Moreover, in Dr. Harum’s medical records filed by respondent, there is
a reference to a C677Y mutation. Resp’s Ex. A at 102. Petitioner was asked to investigate this
question and file any records related to this gene mutation. Order dated Mar. 30, 2015 at 1 (ECF
No. 76).

        Also during the status conference on March 26, 2015, the undersigned addressed the
fundamental flaw in Dr. Harum’s expert reports: the lack of a foundational basis for her
opinions. Order dated Mar. 30, 2015, at 2-3 (ECF No. 76). Petitioner was asked to provide a
supplemental report by Dr. Harum addressing the basis for her opinion that B.A.B. had
encephalopathy and to provide references from the medical records to support her claims. A
review of B.A.B.’s medical records showed that he was developing normally at his nine, 12 and
15 month well-child visits. The Order stated that if petitioner was pursuing a claim that the
vaccines B.A.B. received at his 12 month visit either caused or significantly aggravated an
underlying condition, then petitioner would need to provide evidence that B.A.B. suffered an
injury in the appropriate time frame in relation to his 12 month vaccinations. Lastly, the
undersigned stated that if Dr. Harum was unable to substantiate her expert report, petitioner
should consider dismissing her claim. Id. at 3.

       On April 27, 2015, petitioner filed a status report indicating that she would be filing a
motion for judgment on the record but that she needed additional time to obtain and file Dr.
Harum’s supplemental report, which would address the issues raised in the March 30, 2015
Order. Pet’r’s Status Report dated Apr. 27, 2015 (ECF No. 77). Petitioner’s request for
additional time was granted. Scheduling Order dated Apr. 28, 2015 (ECF No. 78). A similar
request for additional time was made on May 27, 2015, and again that request was granted.
Order dated May 28, 2015 (ECF No. 80).

         On June 3, 2015, petitioner filed a second supplemental expert report by Dr. Harum. See
Pet’r’s Ex. 2913 (ECF No. 81). She also filed a motion for judgment on the record. Motion for
Judgment on the Administrative Record (“MJR”) dated June 3, 2015 (ECF No. 82).14 In the
motion, petitioner stated, “Because the medical records tell the story of [B.A.B.] since his birth,
and the professional opinions support their respective positions, . . . no benefit to the parties
would accrue by conducting a trial.” MJR at 1. A few days later, petitioner filed medical
literature cited by Dr. Harum.15

13
   Petitioner did not provide an exhibit number for this filing. Because she designated medical
literature filed five days later as exhibit 28 (the next available exhibit number), the undersigned
designates Dr. Harum’s second supplemental report as exhibit 29. This report was also filed
along with petitioner’s motion for ruling on the record, as Tab 3. See Motion for Judgment on
the Administrative Record dated June 3, 2015 (ECF No. 82).
14
  Along with her motion, petitioner filed copies of the previously filed expert reports: three by
petitioner’s expert, Dr. Harum, and one by respondent’s expert, Dr. Holmes, as attachments 1-4.
See also Pet’r’s Exs. 19, 26, 29; Resp’s Ex. B.
15
     See Notice dated June 8, 2015 (providing the list of articles comprising Pet’r’s Ex. 28 filed by
                                                  5
        Respondent filed her response on June 17, 2015, asserting that “[t]he [p]etition should be
dismissed.” Resp’s Response dated June 17, 2015, at 13 (ECF No. 84). Respondent argued that
“[p]etitioner has failed to provide any credible evidence that B.A.B. suffered an encephalopathy
as defined by the Act, or that his neurological symptoms were in any way caused by the Proquad
vaccine.” Id. In accordance with the undersigned’s August 19, 2015 Order, respondent filed a
supplemental expert report by Dr. Holmes and additional medical literature on October 2, 2015.
See Resp’s Exs. Q, R (ECF No. 86).

           This case is now ripe for adjudication of petitioner’s motion for a ruling on the record.

     II.       Summary of Relevant Medical Records and Affidavits

              a.   Summary of Medical Records

         B.A.B. was born on April 17, 2006. Pet’r’s Ex. 2 at 1. He had a normal physical
examination and his APGAR scores16 were nine and nine. Id. His newborn screening tests and
hearing examination were normal, and he was discharged home on April 19, 2006. Id. at 1-4.
On May 20, 2006, petitioner called B.A.B.’s pediatrician complaining that B.A.B. had been
crying for twelve hours, he was wheezing, and he seemed to be in pain. Pet’r’s Ex. 4 at 27-28.
On June 16, 2006, B.A.B. was noted to be spitting up and fretful. He was diagnosed with
possible gastroesophageal reflux disease (“GERD”) and mild reflux esophagitis. Pet’r’s Ex. 6 at
1. The treating physician ordered Prevacid. Id. at 1-2. On June 23, 2006, at his two month well-
child visit, he was noted to have nasal congestion. Pet’r’s Ex. 6 at 11. During this visit, B.A.B.
received the DTap, IPV, Hib, Prevnar, and Hepatitis B vaccinations. Pet’r’s Ex. 3 at 2-3. No
adverse reaction was noted. At his four month well-child visit on August 22, 2006, B.A.B. met
all his developmental milestones. Pet’r’s Ex. 6 at 12. On September, 21, 2006, he was
diagnosed with an upper respiratory infection. Pet’r’s Ex. 6 at 2-3.

        At his six month well-child visit on October 25, 2006, B.A.B. again met all his
developmental milestones. Pet’r’s Ex. 6 at 13. B.A.B. received his DTap, IPV, Hib, Prevnar,
and Hepatitis B vaccinations. Pet’r’s Ex. 3 at 2-3. No adverse reactions were documented. On
December 31, 2006, at about eight months old, B.A.B. had a fever of 102.5 but showed no other
signs of serious infection. Pet’r’s Ex. 4 at 22-26.

       On January 1, 2007, B.A.B. presented to the emergency department (“ED”) of Central
Carolina Hospital (“CCH”) with a fever of 105.9, decreased activity, excessive crying,

CD on June 12, 2015). Petitioner re-filed five of the articles previously filed as part of exhibit
27, this time filing the complete articles for the two partially filed on March 11, 2015. Petitioner
also included eight additional references, filing only the abstract or summary for three of these
articles. See Pet’r’s Ex. 28 at 48, 134-36.
16
  Appearance, Pulse, Grimace, Activity, and Respiration (“APGAR”) score is a method of
evaluating newborns to determine their overall health. See NELSON TEXTBOOK OF PEDIATRICS
(19th ed. 2011) at 536-37.

                                                    6
congestion, and nasal discharge. Pet’r’s Ex. 5 at 7-8. His oxygen saturation was excellent at 100
percent, he was otherwise well-appearing, he did not have a rash, and no speech or neurological
problems were noted. Id. B.A.B.’s treating physicians diagnosed him with a fever, likely due to
a virus. Pet’r’s Ex. 6 at 2. While B.A.B. was in the ED, his father called the pediatrician’s after
hours telephone line, “agitated [and] demanding [that a] doctor meet [B.A.B.] in [the emergency
room] as they do not know any of the doctors.” Pet’r’s Ex. 4 at 19. B.A.B.’s father further
reported that his son had a “fever of 107.” Id. Ultimately, B.A.B. left the ED against medical
advice (“AMA”), and his father reported that he was taking his son to the pediatrician’s office.
Pet’r’s Ex. 5 at 6. B.A.B. was seen on January 2, 2007, by his pediatrician, Dr. A.M. Hess. Dr.
Hess documented that B.A.B. had fever up to 106, with minimal runny nose and cough. Pet’r’s
Ex. 6 at 2. His impression was that B.A.B. was experiencing a “fever, [which was] likely viral.”
Id. Dr. Hess saw B.A.B. the next day, January 3, 2007. Although he had experienced a fever for
four days, B.A.B. appeared well during the visit and was in no distress. He had an ulcer on his
tongue and one papule on his wrist, but otherwise, no rash was noted. His hemoglobin level was
normal, and his complete blood count (“CBC”) was “reassuringly viral.” Id.

        At B.A.B.’s nine month well-child visit on January 23, 2007, he again met all his
developmental milestones, and his developmental assessment was normal. Pet’r’s Ex. 6 at 14.
He was using “lots of words” and was able to name colors. Id. On February 5, 2007, he had
chapped cheeks and was diagnosed and treated for facial eczema. Id. at 3. On April 18, 2007,
B.A.B. presented for his 12 month well-child visit and again met all of his developmental
milestones. Id. at 15. His developmental assessment was normal. Id. He received the Prevnar,
MMR, and Varicella vaccines,17 and his physician did not note any adverse reaction. Pet’r’s Ex.
3 at 2-3. There are no entries in the medical record that indicate B.A.B. had any abnormal
neurological condition or symptoms following his 12 month vaccinations.

        On July 13, 2007, B.A.B. presented to CCH for treatment of a lip laceration. Pet’r’s Ex.
5 at 1. His past medical history was noted to be negative, and he appeared alert upon physical
examination. Id. Neurological examination documented that he was oriented, that his mood and
affect was normal, and that he had no sensory or motor deficit. Id. at 2. The nursing record from
that admission notes that his mental status was alert and oriented and that his behavior was
cooperative. Id. at 4. B.A.B.’s parents made several follow up calls to the pediatrician’s office
about the laceration on his face, but no pre-existing conditions or evidence of any problems,
other than the concern about the small laceration on his face, were noted. See Pet’r’s Ex. 4 at 16;
Pet’r’s Ex. 6 at 3. During this time, there is no indication in the medical records that B.A.B.
experienced any neurological problems, especially not any signs or symptoms of encephalopathy
or encephalitis.

        B.A.B. was 15 months old on July 17, 2007. The record does not indicate that he
experienced any medical problems at this time. On August 15, 2007, at about 16 months of age,
B.A.B. had a fever of 103.8, but he had no other symptoms. Pet’r’s Ex. 6 at 3. He looked well
hydrated and was not in acute distress. Other than some pharyngitis and nasal congestion, he
appeared normal and had no other symptoms. Id. A month later, on September 15, 2007, B.A.B.
had a fever with congestion. Pet’r’s Ex. 4 at 13-15; Pet’r’s Ex. 6 at 4. His doctor observed on
September 17, 2007, that B.A.B. was “cranky” but easily consoled, and he appeared well.

17
     These are the vaccinations at issue.
                                                7
Pet’r’s Ex. 6 at 4. His tympanic membranes were red, but there was no pus or bulging, and he
was diagnosed with a viral syndrome. Id. During these visits, there were no symptoms to
suggest that B.A.B. had encephalopathy or encephalitis, nor is there anything in the record to
suggest that the pediatrician even considered either of these diagnoses.

         B.A.B. had his 18 month well-child visit on October 19, 2007. At that visit, petitioner
expressed concerns about B.A.B.’s speech development. She stated that he still had the “same
speech” and “level of skills” that he had at 12 months of age, and that while he was saying quite
a few words, he was not saying new words. He did not seem interested in acquiring new words,
did not respond to his name, but did seem to hear normally. Pet’r’s Ex. 6 at 4. B.A.B. did meet
all of his developmental milestones. Id. at 16. He was drinking from a sippy cup, was able to
say three words plus “mama” and “daddy,” and was able to walk, run and climb. He was able to
scribble, play games, and he tried to use a spoon and fork. Id. His gross motor development was
normal. The pediatrician and petitioner decided to monitor B.A.B.’s developmental progress.
The pediatrician reported, “mom will call [on the] first of the year if [B.A.B.] seems to have
progressed no further.” Id. at 4. During this visit there was no mention of or suggestion that
B.A.B. had encephalopathy or encephalitis, or that he had any prior history of either of these
conditions.

         Approximately one month later, on November 23, 2007, B.A.B. presented to his
pediatrician with fever, lack of appetite, and lethargy. He was diagnosed with right otitis media,
and antibiotics were prescribed. Pet’r’s Ex. 6 at 4. During that visit, the pediatrician noted that
B.A.B. did not speak during the examination, that he did not point, and that he does not “bring
mom into his world if he sees something.” The pediatrician questioned “possible Autism
Spectrum Disorder.” Id. Later that same day, however, when B.A.B. was seen for a possible
allergic reaction to amoxicillin, he was noted to be “doing well” and was running around the
clinic, looking at pictures, and pointing to baby pictures on the walls. Id. at 5. In a follow-up
visit on November 29, 2007, B.AB.’s pediatrician noted that he appeared healthy, playful, and
was eating and drinking normally. Id. at 5-6. The pediatrician further observed that B.A.B.
“seems to exhibit age appropriate behavior, maybe a litlte [sic] bit on the hyperactive side,” and
that “he does not exhibit any signs of systemic illness.” Id. However, his doctor reported that
petitioner was “clearly very preoccupied with what she perceives to be [B.A.B.’s] behavioral
disorder.” Id. at 5. The doctor further recommended “let[ting] the evaluation from TEACCH18
occur first before we make any pronouncement as to whether B.A.B. does have any behavior
abnormalities.” Id. B.A.B.’s pediatrician noted that a lot of petitioner’s concerns “have been
prompted by her reading … on the internet.” Id. at 6. The pediatrician recommended that
petitioner “stick to only resources recommended to her by TEACCH or other reliable healthcare
professionals.” During these visits, there was no reference to any prior history of
encephalopathy or encephalitis, or any prior or current diagnosis of either condition.


18
  Treatment and Education of Autistic and Related Communication Handicapped Children
(“TEACCH”) is a program that provides training and services to families with autistic children.
The program was developed by the University of North Carolina at Chapel Hill. See UNC
School of Medicine, “TEACCH Autism Program,” available at https://www.teacch.com/ (last
visited April 4, 2016).

                                                 8
         On December 6, 2007, a developmental evaluation was performed by Donna A.
Merkwan, Ph.D., an Infant-Toddler-Family Specialist (“ITFS”). The report was issued on
January 22, 2008. Pet’r’s Ex. 7 at 1-3. B.A.B. was referred for testing by his father due to
concerns over his speech development and possible autism. Id. at 2. Entry level tests and results
were as follows: gross and fine motor skills were within normal limits, cognitive skills were
within normal limits, there was a 58 percent delay for chronological age for total language, self-
help/adaptive behavior was within normal limits, and there was a 37 percent delay for
chronological age for socio-emotional Early Learning Accomplishment Profile (“E-LAP”). Id.
Dr. Merkwan questioned whether B.A.B.’s delay in social skills might be “related to his
decreased interaction with other persons.” Id. at 3. Dr. Merkwan also noted that while some of
his repetitive behaviors may seem “autistic-like,” they did not “constitute a definitive diagnosis
for Autism Spectrum Disorder but may [] relate[] to [a] sensory processing disorder or to sensory
integration issues.” Id. Dr. Merkwan recommended that B.A.B. undergo evaluation by the Early
Intervention Service Coordinator (“EISC”) to determine his eligibility for services through the
state’s Infant Toddler Program. Id. Dr. Merkwan did not note any association between B.A.B.’s
vaccines and his delay in language or socio-emotional skills. Dr. Merkwan did not note any
prior history consistent with encephalopathy or encephalitis, and she did not consider any such
prior or current diagnosis.

        On January 17, 2008, Dana Miller, a speech therapist, evaluated B.A.B. Ms. Miller noted
that a Receptive-Expressive Emergent Language Test, Third Edition (REEL-3) revealed that
B.A.B. had a 38 percent language delay, and she recommended speech therapy twice weekly.
Pet’r’s Ex. 10 at 3-4. Occupational testing was performed January 18, 2008, by Melanie Lee,
M.S. She administered the Peabody Developmental Motor Scales, Second Edition (“PDMS-2”)
test to measure B.A.B.’s developmental skills. Based on the test, B.A.B. was age appropriate in
“visual-motor integration and grasping skills.” Id. at 6. However, based upon B.A.B.’s mother’s
answers to the Infant/Toddler Sensory Profile Caregiver Questionnaire, B.A.B. experienced
“differences in how he processes some types of sensory information.” Id. Ms. Lee
recommended occupational therapy (“OT”) sessions once weekly. Id. at 8.

        Additional evaluations were conducted in January and February 2008. On February 4,
2008, B.A.B. underwent a psychological evaluation by John Wilson, MA, LPA, using the Bayley
Scales of Infant Development, Third Edition (“BSID-III”), Cognitive Scale test. Pet’r’s Ex. 7 at
7. During the evaluation process, Mr. Wilson noted that B.A.B.’s family was concerned that his
prior episode of elevated temperature of 107.5 may have impacted his development. B.A.B.’s
score was 100, which “falls in the classification of average performance.” However, he was
performing at approximately a 21 month age equivalence. Id. B.A.B. was also evaluated using
the Childhood Autism Rating Scale (“CARS”) screening, a tool used to identify autism in
children. B.A.B.’s score of 30 was “squarely on the line between non-autistic and the lowest
bound of the mildly/moderately autistic range.” Id. B.A.B.’s scores were inconsistent with a
diagnosis of autism but placed him “on the threshold of symptoms of a mild/moderate autism
spectrum disorder.” Id. at 8.19 It was recommended that B.A.B. see a pediatric neurologist and
that he be evaluated for the TEACCH program. Id. Mr. Wilson did not note any prior history

 The International Statistical Classification of Diseases (“ICD”) billing code for this visit to Dr.
19

Harum was 315.5, which represents Mixed Development Disorder. Pet’r’s Ex. 7 at 8.

                                                 9
consistent with encephalopathy or encephalitis, nor did he note any such prior or current
diagnosis.

        On September 26, 2008, B.A.B. underwent an evaluation by Dr. Karen Harum. Resp’s
Ex. A at 115. Dr. Harum tested B.A.B. for metabolic and neurological disorders in 2009 and
2010. Pet’r’s Ex. 19 at 1. Genetic testing completed on October 16, 2008, for
methylenetetrahydrofolate reductase (“MTHFR”) mutations C677T and A1298C, revealed that
B.A.B. had a single copy of the C677 mutation. Resp’s Ex. A at 102-03. Genetic counseling
was recommended. Id. at 103. Subsequent testing ordered by Dr. Harum reviewed that on
March 4, 2009, B.A.B. had Rubeola AB (Antibodies), IgG, EIA, of 4.79H. Reference limits
stated that greater than 1.09 was positive. Id. at 72. Lab results noted that “[p]resence of
antibodies to Rubeola is presumptive evidence of immunity except when active infection is
suspected.” Id. Additional tests for complete blood count with differential and comprehensive
metabolic panel returned all normal results, except for elevated blood urea nitrogen
(“BUN”)/Creatinine Ratio of 59 H, with a reference range of eight to 27. Id. at 71. Testing for
interleukin-2 receptor alpha (“IL-2R”) performed in September 2008 and March 2009 showed
that B.A.B.’s levels were elevated. Id. at 72, 103. B.A.B.’s Neuron-specific enolase was
elevated in September 2008, but repeat testing showed that this was normal. Id. at 103, 72.
Repeat testing of B.A.B.’s BUN/creatinine ratio remained elevated with a score of 52 in March
2010, and a repeat test of IL-2R alpha performed in March 2010 was normal. Id. at 70. Vitamin
D and Ferritin testing completed in March 2010 revealed low results. Id. On October 8, 2009,
B.A.B. had an EEG, which was normal. Id. at 94.

         On October 7, 2008, at B.A.B.’s two year old well-child visit to his pediatrician,20 he met
all of his developmental milestones. Pet’r’s Ex. 6 at 19. He was using two words together,
drawing/scribbling, running, climbing, throwing a ball and kicking. His parents reported that
B.A.B. was making progress in PT, OT, and speech therapy and that he was undergoing an
evaluation for ASD. Id.

        On April 14, 2009, when B.A.B. was almost three years old, he was seen by Dr. Vinod
Doreswamy at UNC Hospital, located in Chapel Hill, North Carolina, due to his parents’
concerns regarding his elevated measles titer, his underlying developmental delay, and his
recurrent fevers. Pet’r’s Ex. 12 at 6. With regard to B.A.B.’s positive measles titer, Dr.
Doreswamy opined that this “does not seem to be reflective of anything else other than a good
vaccine response.” Id. at 8. Dr. Doreswamy also noted that B.A.B. was “playing appropriately
with toys, had short meaningful sentences in response to question[s], and made good eye
contact.” Id. With regard to the recurrent fevers, Dr. Doreswamy recommended genetic testing
and conservative measures, including antipyretics for fever. Id. Dr. Doreswamy did not
diagnose B.A.B. with encephalopathy or encephalitis, nor did he note any prior history of either
condition. Dr. Doreswamy did not implicate B.A.B.’s vaccinations as causally associated or
related to any of his medical problems or his parents’ concerns.



20
  The undersigned notes that B.A.B. was actually two and a half years old at this visit. See
Pet’r’s Ex. 6 at 19.

                                                 10
         On July 6, 2009, B.A.B. was evaluated by Dr. Lynn M. Wegner of UNC to consult
regarding further interventions for his developmental delay. B.A.B. was transitioned out of the
North Carolina Infant Toddler Program when he reached three years of age. Pet’r’s Ex. 12 at 1.
Dr. Wegner reviewed B.A.B.’s prior testing results and progress with speech and OT therapies.
Id. at 1-2. Dr. Wegner opined that B.A.B. had “made incredible progress with the therapies
offered” and expressed her concern about B.A.B. being withdrawn from school system support.
Id. at 4. Dr. Wegner recommended that B.A.B. undergo updated language and fine motor
integration assessments, that his school reinstate his Americans with Disabilities Act (“ADA”)
therapy, and that he have an Individualized Education Program (“IEP”) to address language
issues and fine and gross motor issues. Id. Dr. Wegner did not diagnose B.A.B. with
encephalopathy or note any prior history of encephalopathy or encephalitis. Dr. Wegner did not
document any issues associated with B.A.B.’s vaccinations, nor did she note any association
between B.A.B.’s vaccinations and his developmental delay.

        On January 4, 2010, B.A.B. was given a diagnosis of autism (ICD 299.00).21 See Pet’r’s
Ex. 20a at 19. On March 3, 2010, B.A.B. met the criteria to be placed on a waiting list for
specialized services under the Community Alternative Program for Persons with Mental
Retardation and/or Developmental Disabilities (“CAP-MR/DD”). Pet’r’s Ex. 11 at 1. On April
5, 2010, at approximately four years of age, B.A.B. had swollen tonsils and congestion, and he
was diagnosed with strep pharyngitis. Pet’r’s Ex. 6 at 9. At that visit, the pediatrician noted that
B.A.B. had features consistent with autism. Id.

         B.A.B. underwent a psychological evaluation by Christine Hook, Ph.D., on June 14,
2010, at the age of four years and two months. Pet’r’s Ex. 20a at 3. Dr. Hook administered a
battery of tests, including the Wechsler Preschool and Primary Scale of Intelligence (“WPPSI-
III”), Vineland Adaptive Behavior Scales (“Vineland-II”), Behavior Assessment System for
Children (“BASC-2”), and Gillian Autism Rating Scale (“GARS-2”). In summarizing the test
results, Dr. Hook noted that B.A.B. possessed good vocabulary skills and that his social skills
had improved, but that he continued to struggle with following directions. Id. at 7. She also

21
   At that time, ICD 299.00 was the diagnostic code for autism. Centers for Medicare &
Medicaid Services, “ICD-9 Code Lookup,” available at https://www.cms.gov/medicare-
coverage-database/staticpages/icd-9-code-
lookup.aspx?KeyWord=299.00&bc=AAAAAAAAAAAEAA%3d%3d&# (last visited April 4,
2016). Autism is characterized by “[p]ersistent deficits in social communication and social
interaction across multiple contexts,” as well as “restricted, repetitive patterns of behavior,
interests, or activities.” The Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 4th ed. text revision 2000) (“DSM-IV-TR”). A comprehensive
discussion of the symptoms of autism can be found at White v. Sec’y of Health & Human Servs.,
No. 04-337V, 2011 WL 6176064, at *4-9 (Fed. Cl. Spec. Mstr. Nov. 22, 2011). The DSM-IV-
TR has since been replaced by the Diagnostic and Statistical Manual of Mental Disorders,
(American Psychiatric Association, 5th ed. 2013) (“DSM-V”), which uses the term “ASD”, but
the discussion of the symptoms of autism found in White is still relevant. In the DSM-V, the
symptoms recognized by the medical community at large as those of an ASD have not changed,
but the criteria for diagnosis have been refined, and the distinctions drawn in the DSM-IV among
the diagnoses of autistic disorder, PDD-NOS, and Asperger’s disorder have been eliminated.

                                                 11
noted that he had a “high level of over activity and impulsivity” as well as issues with sensory
processing. Id. Dr. Hook concluded that B.A.B. met the criteria for Autistic Disorder and
recommended a number of treatment strategies, including OT and continued programs in the
school setting. Id. at 7-9. During this evaluation, Dr. Hook noted that B.A.B.’s “mother
expressed concerns that [B.A.B.’s] regression was . . . possibly [related] to vaccines he
received.” The physician records indicate that the improbability of this correlation was discussed
with B.A.B.’s parents. Id. at 3.

           b. Statements from B.A.B.’s Parents

        The record includes statements given by B.A.B.’s father, Tre Benson, and his mother,
petitioner Erica Benson (Fester). See Pet’r’s Ex. 14; Pet’r’s Ex. 15. Mr. Benson stated that
shortly after B.A.B.’s first birthday and shortly after receiving the MMRV vaccine, his cousin,
who was approximately B.A.B.’s same age, came over to stay at B.A.B.’s home for about one
week. During this time, Mr. Benson stated that B.A.B.’s cousin was often fussy, which made
B.A.B. very angry. He reported that “[B.A.B.] smacked his cousin every chance he got” and
would have “frequent temper tantrums,” some of which would last for over an hour. Pet’r’s Ex.
14 at 1. Mr. Benson reported that shortly thereafter, B.A.B. bit petitioner and that his temper
tantrums worsened to the point that B.A.B. would not look his parents in the eye. Id. at 2.

        Mr. Benson also reported events from the day that B.A.B. received the MMRV
vaccination on April 18, 2007. He stated that B.A.B. had been crying and upset all day after
receiving the vaccines and that afterwards he stopped talking altogether and did not say anything
for almost a year. Pet’r’s Ex. 14 at 2-3. Mr. Benson stated, “[t]hings sort of started rolling
downhill from there, little by [little, my] son started eroding into a different little boy.” Id. at 3.
Mr. Benson detailed the progression of his son’s doctor’s appointments leading to his diagnosis
of autism, highlighting the difficult impact of his son’s disease on the family. Id. at 6.

        Petitioner’s statements similarly highlighted the alleged changes in her son’s behavior
that seemed to arise shortly after his vaccinations on April 18, 2007. She reported that B.A.B.
“wouldn’t stop crying or being upset, had a fever[,] and wouldn’t take his normal nap” that
afternoon. Pet’r’s Ex. 15 at 1. Petitioner stated that after April 2007, B.A.B. exhibited hostile
behaviors, he became interested with repetitive actions, and his eye contact lessened. She further
reported that “he was always sick with a cold or mild illness and always had a low fever.” Id.
She described that as her son’s condition worsened, he “stopped responding to his name or
looking at us, not noticing or caring if we were in the room.” Id. Given her growing concern,
she eventually sought child development services to evaluate her son. Id.

   III.    Standards for Adjudication

        The Vaccine Act established the Program to compensate vaccine-related injuries and
deaths. § 10(a). “Congress designed the Vaccine Program to supplement the state law civil tort
system as a simple, fair and expeditious means for compensating vaccine-related injured persons.
The Program was established to award ‘vaccine-injured persons quickly, easily, and with
certainty and generosity.’” Rooks v. Sec’y of Health & Human Servs. 35 Fed. Cl. 1, 7 (1996)
(quoting H.R. REP. NO. 908 at 3, reprinted in 1986 U.S.C.C.A.N. at 6287, 6344).

                                                  12
       To receive compensation under the Program, petitioner must prove either: (1) that B.A.B.
suffered a “Table Injury”—i.e., an injury listed on the Vaccine Injury Table—corresponding to a
vaccine that he received, or (2) that B.A.B. suffered an injury that was actually caused by the
vaccine (or vaccines) he received. See §§ 13(a)(1)(A) and 11(c)(1); Capizzano v. Sec’y of
Health & Human Servs., 440 F.3d 1317, 1319-20 (Fed. Cir. 2006).

        Although the Vaccine Table includes an injury of encephalopathy (or encephalitis)
suffered five to 15 days after administration of the MMRV vaccine or one of its components,22
petitioner is not alleging a Table Injury. See Petition at 1. Moreover, in order to qualify as a
Table Injury, the encephalopathy petitioner claims B.A.B. suffered would have to satisfy the
more narrow definition of encephalopathy contained in the Qualifications and Aids to
Interpretation (“QAI”) section of the Vaccine Injury Table.23 The medical records and expert
reports from Dr. Harum would not support an allegation of a Table encephalopathy, even if
made.

        Because petitioner cannot show that B.A.B. suffered a Table injury, she must prove that a
vaccine B.A.B. received caused his injury. To do so, she must establish, by preponderant
evidence: (1) a medical theory causally connecting a vaccine and B.A.B.’s injury (“Althen Prong
One”); (2) a logical sequence of cause and effect showing that a vaccine was the reason for his
injury (“Althen Prong Two”); and (3) a showing of a proximate temporal relationship between a
vaccine and his injury (“Althen Prong Three”). Althen v. Sec’y of Health & Human Servs., 418
F.3d 1274, 1278 (Fed. Cir. 2005); § 13(a)(1) (requiring proof by a preponderance of the
evidence).

      IV.    Expert Opinions

       In support of her claim, petitioner offers the expert reports of Dr. Harum. See Pet’r’s
Exs. 19, 26, 29. Respondent provides the expert reports of Dr. Holmes. See Resp’t Exs. B, Q.
Both experts disagree as to the nature and cause of B.A.B.’s condition. Furthermore, Dr. Holmes
extensively criticizes the factual predicates upon which Dr. Harum bases her opinion.




22
     42 C.F.R. § 100.3(a)(III)(B) (2015).
23
  See 42 C.F.R. § 100.3(b)(2). As explained in Waddell, “[t]he scope of the medical term
‘encephalopathy’ is more expansive than the narrower, statutory definition set forth in the
Table.” Waddell v. Sec’y of Health & Human Servs., No. 10-316V, 2012 WL 4829291, at *12
(Fed. Cl. Spec. Mstr. Sept. 19, 2012) (referencing Hazlehurst v. Sec’y of Health & Human
Servs., No. 03-654V, 2009 WL 332306, at *26-29 (Fed. Cl. Spec. Mstr. Feb. 12, 2009)).
Encephalopathy as generally used means “any degenerative disease of the brain.” DORLAND’S
ILLUSTRATED MEDICAL DICTIONARY, 614 (32nd ed. 2012) (“DORLAND’S”). “The QAI definition
of acute encephalopathy simply does not encompass every type of brain dysfunction to which the
broader meaning of ‘encephalopathy’ applies.” Blake v. Sec’y of Health & Human Servs., No.
03-31V, 2014 WL 2769979, at *6 (Fed. Cl. Spec. Mstr. May 21, 2014).

                                                13
             a. Petitioner’s Expert, Dr. Karen Horton Harum

         Dr. Harum is a board-certified pediatrician and specializes in the area of
neurodevelopmental disabilities. Pet’r’s Ex. 19 at 6. She attended medical school at the
University of Miami School of Medicine and completed her internship at the University of
Florida School of Medicine, Shands Teaching Hospital. Dr. Harum completed her residency in
pediatrics at the University of Miami School of Medicine. She then completed a fellowship in
neurodevelopmental pediatrics at the Kennedy Krieger Institute, at the Johns Hopkins University
School of Medicine. Thereafter, she served as a post-doctoral fellow at the Kennedy Krieger
Research Institute and received a National Research Service Award in Neuroscience. Dr. Harum
is currently in private practice in Wilmington, North Carolina, at the Clinic for Special Children.
Id. at 4-8.

                     i. B.A.B.’s Injury and Diagnosis

        The most comprehensive explanation of Dr. Harum’s opinions in this case is set forth in
her third expert report (second supplemental report). As in all of her other reports, Dr. Harum
describes B.A.B.’s injury as “subclinical encephalopathy, the manifestations of which are
developmental regression, loss of language and sensory processing deficits.” Pet’r’s Ex. 29 at 4,
filed June 3, 2015 (ECF No. 81). Dr. Harum defines “subclinical” encephalopathy as a subtle
but not acute process that the parents could recognize, but “not obvious enough for the
pediatrician to be concerned about.” Id. She defines “encephalopathy” as a “sub-acute
neurologic dysfunction: language plateau, loss of language, loss of auditory awareness, loss of
visual attention, and decreased level of activity.” Id. at 5. More specifically, Dr. Harum defines
“regressive encephalopathy” as “neurological impairment of unknown cause that is associated
with a period of past or on-going regression.” Id. She explains that “30 [percent] of children
ultimately diagnosed with autism have experienced developmental regression and other
neurological changes, including subtle EEG changes.” Id.

        In her initial expert report, Dr. Harum describes B.A.B. as suffering symptoms
“indicative of encephalopathy,” and adding that “the symptoms of associated with Autism
Spectrum Disorder are nearly identical.” Pet’r’s Ex. 19 at 3. She expands on this description in
her second expert report (first supplemental report), opining that based on her “assessment at 29
months of age and the DSM-IV criteria, [B.A.B.] met [the]3 criteria for high functioning autism
following encephalopathic regression.” Pet’r’s Ex. 26 at 4. Dr. Harum states that her diagnosis
is consistent with John Wilson, Ph.D.’s diagnosis of autism when B.A.B. was 21 months of age,
and Dr. Lynn Wegener’s diagnosis of autism at 39 months of age.

                    ii. Medical Theory of Causation

        In her initial expert report, Dr. Harum opined that vaccines, including the measles
vaccine, can cause infectious encephalitis, particularly in immune compromised children, and
that encephalitis may thereafter result in developmental regression. Dr. Harum quotes the
Institute of Medicine (“IOM”)’s Adverse Effects of Vaccines: Evidence and Causality,24 as
follows:

24
     Institute of Medicine (“IOM”), Adverse Effects of Vaccines: Evidence and Causality, 110
                                                14
          There is mechanistic evidence of vaccine reactions that does account for
          acute onset of infections and deterioration, but also for delayed onset of
          infection, delayed up to [nine] months after vaccine administration. For
          example, the measles vaccine can cause measles inclusion body encephalitis
          due to the vaccine strain of measles, after administration of the measles
          vaccine, particularly in immune compromised individuals up to [nine]
          months after the vaccine administration.

Pet’r’s Ex. 19 at 2 (quoting IOM at 110).

         Dr. Harum further posited that “there is a plausible body of evidence to associate MMRV
and other vaccines and encephalitis resulting in mental retardation and speech impairment.
Therefore, one can postulate that there is a plausible association between MMRV and other
vaccines and subacute encephalopathy associated with developmental regression.” Pet’r’s Ex.
19 at 2.

        Subsequently, former Chief Special Master Vowell identified a number of problems with
Dr. Harum’s medical theory as stated in her initial expert report. See Order dated Jan. 9, 2015
(ECF No. 68). First, “[t]he medical records and the parents’ early statements do not support the
existence of encephalitis after the 12 month vaccinations.” Id. at 1-2. Additionally , “Dr. Harum
mention[ed] “‘subclinical’ encephalitis [in her report] but fail[ed] to point to any evidence that
one existed, or that subclinical encephalitis can result in an autism diagnosis.” Id. at 2.
Moreover, “none of the articles or excerpts filed provide[] support for . . . Dr. Harum’s theory:
that the 12 month vaccines caused encephalitis that manifested with autism-like symptoms.” Id.
In conclusion, Chief Special Master Vowell stated, “[i]n essence, Dr. Harum strings together
reported effects from MMR vaccines to conclude that MMR can cause autism or cause a
condition resulting in ‘autism-like’ symptoms, in spite of a dearth of evidence that B.A.B. had
symptoms of encephalitis or encephalopathy in the months after his Proquad vaccination.” Id.

         In her next supplemental report, Dr. Harum conceded that “there [was] no evidence of
encephalitis following the 12 month vaccinations.” Pet’r’s Ex. 26 at 1. After this concession,
however, Dr. Harum changed tack. Instead of arguing that the 12 month vaccines caused an
acute or delayed infectious encephalitis or encephalopathy, manifested with autism-like
symptoms, in her second and third expert reports, Dr. Harum posited a multi-faceted framework,
built on a series of presumptions. Dr. Harum opined that B.A.B. “contracted roseola infantum[25]
at [nine] months of age, coincident with granulocytopenia and symptoms of encephalopathy,
including language plateau.” Pet’r’s Ex. 26 at 3; accord. Pet’r’s Ex. 29 at 8. Then, within
“[three] months, while there was ongoing lymphocytosis and presumed brain inflammation, and
in this immune dysregulated state, [B.A.B.] received a cluster of vaccines that contributed further
to microglial activation, overactive Th2 immunity, and worsening encephalopathy.” Pet’r’s Ex.

(Kathleen Stratton et al. eds., 2012) (internal citations removed).
25
  Roseola Infantum is clinically defined as “a type of rose-colored rash seen most often in an
infectious disease such as measles or other exanthematous diseases.” DORLAND’S at 1654.

                                                 15
26 at 3. Dr. Harum argued that the vaccines further contributed to “this injury pathway through
the load of aluminum, glutamate, formaldehyde and unidentified pathogens” found in the
vaccines. Pet’r’s Ex. 26 at 3; accord Pet’r’s Ex. 29 at 8.26 Dr. Harum writes that these
mechanisms contributed to B.A.B.’s “encephalopathic regression through pathophysiologic
mechanisms described repeatedly in neuronal injury in the scientific literature.”27 Pet’r’s Ex. 29
at 9.

        In her third and final supplemental report, Dr. Harum elaborates upon several direct
questions posed by former Chief Special Master Vowell in an earlier scheduling order. See
Order dated January 9, 2015 (ECF No. 68). Dr. Harum posits that B.A.B. had a C667T
mutation, the significance of which was “very limited, except under circumstances of folate
deficiency.” Pet’r’s Ex. 29 at 1. Dr. Harum then states, “[I]f other undiagnosed problems within
the methylation cycle . . . are also present, it weakens the individual’s ability to provide methyl
groups to a wide variety of molecules. Under these circumstances, glutathione production can be
limited by insufficient methylation cycle activity.” Id. Dr. Harum continues by stating that
issues with the methylation cycle can inhibit methyl production, which thus limits production of
glutathione, which helps protect the body from toxins. Id. These inhibitions of methylation
pathways, according to Dr. Harum, can cause “adjuvants such as alum [to] pose a greater toxic
effect.” Id. at 2.

        Dr. Harum summarizes her opinion of how B.A.B. suffered an encephalopathy by first
stating that B.A.B. suffered from roseola infantum in January 2007 at the age of nine months.
She then states, “[roseola infantum] may have caused a mild and temporary encephalitis that
predisposed [B.A.B.] to further neurological inflammation and insult.” Pet’r’s Ex. 29 at 3.
However, in the same paragraph, Dr. Harum admits that B.A.B. “did not have seizures,” that he
“did not have [cerebro-spinal fluid] assays to document HHV-6 in the central nervous system,”
and that “he did not meet the criteria for encephalitis.” Id. Surprisingly, however, Dr. Harum
characterizes the alleged encephalopathy suffered by B.A.B. as “mild and temporary,” which
“predisposed him to further neurological inflammation and insult.” Id. After he received his 12
month vaccines, Dr. Harum stated that B.A.B. then “suffered subclinical encephalopathy”
between the age of 12 and 18 months, opining that his encephalopathy is “described as sub
clinical because it was not acute and was subtle enough for parents to recognize, but not obvious
enough for the pediatrician to be concerned about . . . .” Id. at 4.



26
  Here, Dr. Harum cited to Campbell et al., “Chronic Exposure to Aluminum in Drinking Water
Increases Inflammatory Parameters Selectively in the Brain,” 75 J. NEUROSCI. RES. 565-72
(2004) (complete article filed as Pet’r’s Ex. 28 at 40-47); and M. Giangaspero et al., “Genotypes
of Pestivirus RNA Detected in Live Virus Vaccines for Human Use,” 63 J. VET. MED. SCI. 723-
33 (2001) (abstract only, filed as Pet’r’s Ex. 28 at 134).
27
  In support of this assertion, Dr. Harum cited Atladottir, Thorsen, Schendel, et al., “Association
of Hospitalization for Infection in Childhood with Diagnosis of Autism Spectrum Disorders: A
Danish Cohort Study,” 164 ARCH PEDIATR. ADOLESC. MED., 470-77 (2010) (abstract only from
the National Center for Biotechnology Information website, filed as Pet’r’s Ex. 28 at 135-36).

                                                16
       Finally, Dr. Harum stated that several of B.A.B.’s laboratory test results indicate that he
suffered some sort of subclinical encephalopathy. She points to abnormal folate insufficiency,
oxidized DNA, reduced glutathione, irregular neuron specific enolase (“NSE”) levels, abnormal
IgG total count, and Il-2 receptor alpha elevation, positing that all of these “abnormalities”
suggest that B.A.B. “clearly has an encephalopathy.” Pet’r’s Ex. 29 at 6.

        To evaluate the viability of this theory, the undersigned will separately examine each of
Dr. Harum’s presumptions. The undersigned will review both the foundation for each
presumption and the supporting medical literature. While the undersigned has reviewed and
considered all the evidence in this case and the entire record as a whole, the following is by no
means a complete recitation of all the relevant facts and evidence considered. See § 300aa-13(a)
(stating that the special master should consider the “record as a whole”).

                          1. Dr. Harum’s Theory Part 1

        The first presumption made by Dr. Harum is that B.A.B. contracted roseola infantum at
nine months of age. Pet’r’s Ex. 29 at 8. Dr. Harum initially saw B.A.B. when he was 29 months
of age, so she necessarily relies on medical records for evidence of this part of her opinion. She
writes that B.A.B. “contracted a febrile illness characterized by fever over 105 degrees at 9
months of age . . . later determined to be roseola infantum.” Pet’r’s Ex. 26 at 1.

        The medical records, however, do not show that B.A.B. was diagnosed with roseola
infantum at nine months of age. On January 1, 2007, B.A.B. presented to CCH ED with a fever
of 105.9, decreased activity, excessive crying, congestion and nasal discharge. Pet’r’s Ex. 5 at 7-
8. B.A.B’s oxygen saturation was excellent at 100 percent, he was otherwise well-appearing, he
did not have a rash, and the treating physician did not observe any speech or neurological
problems. Id. B.A.B. was diagnosed with a fever of likely viral origins. Pet’r’s Ex. 6 at 2. On
January 3, 2007, B.A.B. was again seen by his pediatrician, who noted that B.A.B. had an
ongoing fever for four days but that he was “well appearing.” Id. The pediatrician next saw
B.A.B. on February 5, 2007, and at that time noted a rash but no fever. Id. at 3. B.A.B. was
examined and evaluated by a pediatrician on three different dates during this febrile illness, but
not once was he diagnosed with roseola infantum or noted to have any neurological
abnormalities.

        B.A.B. was not diagnosed with roseola infantum until February 4, 2008, at 22 months of
age, when he presented at his pediatrician’s office with a diffuse body rash, described as a
“diffuse pink MP (maculopapular) rash which blanches on extremities and torso.” Pet’r’s Ex. 6
at 7. In addition to specifically describing the rash, the pediatrician documented that “this is a
normal viral pattern specifically that of roseola.” Id. At that point, B.A.B. was 22 months of
age, and nearly 10 months had passed since he received the vaccines at issue. Thus, the
undersigned finds Dr. Harum’s opinion that B.A.B. suffered from roseola infantum at the age of
nine months unpersuasive.

                          2. Dr. Harum’s Theory Part 2

        In order to continue the evaluation of Dr. Harum’s theory, the undersigned next assumes,
for the sake of argument, that B.A.B. did have roseola infantum at nine months of age, or that his
                                                17
viral illness was the equivalent of that condition. Dr. Harum’s next presumption is that the
illness (i.e. the alleged roseola infantum) was “coincident with granulocytopenia and symptoms
of encephalopathy including language plateau.” Pet’r’s Ex. 26 at 3. Granulocytopenia is defined
as a “reduction in the number of granular leukocytes in the blood.”28 Dr. Harum opined, “Lab
evidence demonstrated a . . . low granulocyte count.” Id. at 1. B.A.B.’s blood work from
January 3, 2007, does show decreased granular leukocytes. Id. at 25. B.A.B.’s pediatrician at
the time documented that a CBC had been performed and that the results were “reassuringly
viral.” Id. at 2.

         Thus, while Dr. Harum is correct that B.A.B. had granulocytopenia, in that he had
decreased granular leukocytes, this was a product of a reassuring immune response to his viral
illness, as evidenced by his pediatrician’s contemporaneous record. Moreover, Dr. Harum failed
to provide support for her position that roseola infantum or any other viral illness causes or
contributes to encephalopathy or language plateau. And in fact, in her third supplemental report,
Dr. Harum concedes that on April 18, 2007, “prior to [B.A.B.’s] cluster of vaccines, [his]
granulocytopenia . . . resolved and he appeared quite healthy with normal developmental
milestones.” Pet’r’s Ex. 29 at 3.

        Despite her acknowledgment that B.A.B.’s roseola infantum resolved prior to receiving
his 12 month vaccinations, Dr. Harum opined that roseola infantum is associated with HHV-6,
“an encephalitic virus, with a predilection for brain infection and latent colonization of neuronal
tissue.” Pet’r’s Ex. 26 at 1. However, she concedes that B.A.B. did not have seizures, that there
was no testing of his cerebrospinal fluid, and thus that there is no evidence of HHV-6 in his
brain. Nevertheless, she argues that this HHV-6 infection, of which there is no evidence, caused
encephalopathy, “based on the history of regression.” Id. B.A.B. did not show regression at nine
months, and according to his pediatrician’s records and his parents’ early statements, he did not
experience any developmental delays until he was 15 months old. There are no facts to support
Dr. Harum’s underlying premise that B.A.B. had any abnormal process in play prior to receiving
his 12 month vaccinations. Thus, there is no basis for the first tenet of Dr. Harum’s theory, that
B.A.B. “contracted roseola infantum at 9 months of age, coincident with granulocytopenia and
symptoms of encephalopathy including language plateau.” Id. at 3.

        Similarly, Dr. Harum argues that the vaccines were given in proximity to a “significant
encephalitic virus infection.” Pet’r’s Ex. 26 at 3. In her later report, the “significant encephalitic
virus infection” is downgraded to a “mild and temporary encephalitis.” Pet’r’s Ex. 29 at 3. Dr.
Harum conceded, however, that B.A.B. “did not meet the criteria for encephalitis.” Id. She
specifically stated, “I concede that there is no evidence of encephalitis following the 12 month
vaccinations.” Id. at 4. Moreover, the medical literature Dr. Harum cites to support this part of
her proposed medical theory is insufficient to show roseola, or any other viral illness, coincident
with one transient episode of granulocytopenia, causes or is diagnostic of encephalitis or
encephalopathy, manifest by language plateau, which “predisposed [B.A.B.] to further
neurological inflammation and insult.” Id.

         Dr. Harum claims the “mechanisms of injury” she describes are “described repeatedly” in

28
     DORLAND’S at 803.

                                                 18
scientific literature and cites Atladottir, et al.29 to support her claim. Pet’r’s Ex. 29 at 9.
However, petitioner has filed only the abstract of this article, and it does not provide the support
Dr. Harum claims. See Pet’r’s Ex. 28 at 135-36. The abstract describes a Danish population-
based cohort study that examines whether there is an association between infections requiring
hospitalization and ASDs. Id. at 135. The study found that there was an increase in ASD
diagnoses and mental retardation in these hospitalized children, but the authors observed that this
association was found for children suffering from noninfectious diseases and infectious diseases
that were both bacterial and viral in origin. The authors specifically concluded that the
association found did not suggest causality because the association was observed throughout
these different groups. Id.

        To support her claim that “mechanisms [of injury] converge onto the more recently
described neuronal pathways and signaling systems identified as impaired in autism,” Dr. Harum
cites the Pinto article.30 This article examines the genetic variations involved in ASDs. Pet’r’s
Ex. 27 at 35. The authors concluded that the studies performed “highlighted a striking degree of
genetic heterogeneity, implicating both de novo germline mutation and rare inherited ASD
variation distributed across numerous genes.” Id. 36. It did not, however, provide support for
Dr. Harum’ claims. The article does not mention vaccines.

       Repeatedly throughout her expert report, Dr. Harum makes conclusory statements that
language plateau, developmental regression, and sensory processing deficits are symptoms or
manifestations of encephalopathy. Pet’r’s Exs. 26 at 1; 29 at 4. But she does not offer any
support for these conclusory statements, especially in light of the facts and circumstances of this
case. Moreover, these are some of the most common symptoms of ASD. See White, 2011 WL
6176064, at *4-9. B.A.B.’s first symptom, speech delay, is generally the first symptom observed
by parents of autistic children. Id. at *8. Dr. Harum does not provide any evidence to support a
conclusion that B.A.B.’s symptoms should be categorized as encephalopathy rather than autism.

        Dr. Harum stated that because B.A.B. had an elevated neuron specific enolase (“NSE”)
level of 17.4 on September 29, 2008, approximately one and one-half years after his
vaccinations, this is evidence of neuronal death and encephalopathy. Pet’r’s Ex. 29 at 6; see
Pet’r’s Ex. 9 at 10 (reporting B.A.B.’s test results). She does not explain, however, why B.A.B.
would have normal NSE results six months later, on March 4, 2009, if he were experiencing
“ongoing neuronal injury.” See Pet’r’s Ex. 29 at 6.

       In support of her opinion that B.A.B.’s elevated NSE levels are consistent with an
“ongoing neuronal injury,” Dr. Harum cited a study by Berger, et al.31 regarding infants and

29
     See supra note 27.
30
  Pinto et al., “Convergence of Genes and Cellular Pathways Dysregulated in Autism Spectrum
Disorders,” 94 AM. J. HUMAN GENETICS, 677-94 (2014) (filed twice at Pet’r’s Ex. 27 at 35-52
and Pet’r’s Ex. 28 at 86-103). The undersigned will cite to the article filed as part of Pet’r’s Ex.
27.
31
  Berger et al., “Neuron-Specific Enolase and S100B in Cerebrospinal Fluid After Severe
Traumatic Brain Injury in Infants and Children,” 109 PEDIATRICS E31 (2002) (filed as Pet’r’s Ex
                                               19
children who have experienced traumatic brain injuries (“TBI”). See Pet’r’s Ex. 27 at 2. The
Berger researchers surveyed 10 pediatric patients ranging in ages from two months to nine years
who were admitted to the Children’s Hospital of Pittsburgh with both inflicted and non-
inflicted32 TBI. Id. at 3. The researchers tested the children’s cerebrospinal fluid (“CSF”) for
the presence of NSE, hypothesizing that the concentration of NSE in children is higher after a
TBI. Indeed, the study found that patients with inflicted TBI experienced “an initial peak in NSE
concentration on day 1 after injury followed by a second, higher peak that was sustained for up
to 8 days.” Id. at 4. In patients with non-inflicted TBI, “the initial concentration [of NSE] was
the peak concentration,” meaning that the patients experienced their peak NSE levels shortly
after the initial injury that lead to the TBI. Id.

         Dr. Harum’s citation to the Berger study in support of her contention that B.A.B.
experienced an “ongoing neuronal injury” is erroneous for several reasons. First, petitioner does
not contend, and the record does not reflect, that B.A.B. ever suffered from an inflicted TBI.
However, even if B.A.B. had suffered an inflicted TBI, the NSE levels from the patients in the
Berger study peaked one day after injury and were only sustained for up to eight days after
injury. Pet’r’s Ex. 27 at 4. B.A.B.’s elevated NSE levels were not measured until one and a half
years after he received the MMRV vaccination at issue here. Thus, the results of the study are
inapplicable to B.A.B. The Berger study actually disproves Dr. Harum’s theory that B.A.B.’s
elevated NSE levels point to an “ongoing neuronal injury” that resulted from the vaccinations he
received on April 18, 2007. Assuming the Berger study is applicable to B.A.B.’s case, the
results of the study suggest that his elevated NSE levels on September 29, 2008, were actually
the result of a much more recent injury than the vaccines he received more than five months
earlier.

                          3. Dr. Harum’s Theory Part 3

        The next part of Dr. Harum’s medical theory is that within “3 months [of having roseola
– at age nine months], while there was ongoing lymphocytosis33 and presumed brain
inflammation, and in this immune dysregulated state, [B.A.B.] received a cluster of vaccines that
contributed further to microglial activation, overactive Th2 immunity, and worsening
encephalopathy.” Pet’r’s Ex. 26 at 3.

        With respect to Dr. Harum’s contention that B.A.B. experienced an “ongoing
lymphocytosis,” a CBC with differential was performed on January 3, 2007, when B.A.B. had a
fever and was diagnosed with a viral illness. See Pet’r’s Ex. 6 at 25. B.A.B.’s lymphocyte levels

27 at 1-8).
32
  The Berger researchers note that there are two sub-groups of TBI: inflicted and non-inflicted.
Pet’r’s Ex. 27 at 2. “The mechanism of [inflicted] TBI – violent shaking often followed by
impact with a hard surface – is unlike any of the mechanism of [non-inflicted] TBI and is
particularly deleterious to the brain.” Id. at 3.
33
  Lymphocytosis is defined as an “excess of normal lymphocytes in the blood.” DORLAND’S at
1085.

                                               20
were normal at that time. Id. The CBC was repeated on April 18, 2007, at the time of his 12
month checkup when he received the vaccinations at issue in this case, and again his lymphocyte
levels were in the normal range. Id. at 24. Dr. Harum writes that on April 18, 2007, B.A.B. had
a “low normal granulocyte count and high lymphocyte count . . . reflecting ongoing activation
following a viral infection.” Id. at 2. But the laboratory results identify the white blood cell
count, the granulocyte count, and the lymphocyte count as being within normal limits. Id. at 24.

        Furthermore, there is no indication in the pediatrician’s records that B.A.B. experienced
any “ongoing activation” or other abnormal immune response. See Pet’r’s Ex. 6 at 15. In fact, at
his 12 month visit, B.A.B.’s physical exam, including his neurological exam, was completely
normal. Id. No parental concerns are noted and no follow up was needed. Id. B.A.B.’s parents
did not call or visit his pediatrician after the 12 month visit until July 13, 2007, when B.A.B.
lacerated his lip. There is no indication of illness whatsoever during this time frame. Moreover,
on October 7, 2008, at approximately 18 months of age, a repeat CBC again showed normal
granulocyte and lymphocyte levels. Id. at 21. Dr. Harum’s conclusions that B.A.B. had ongoing
lymphocytosis or that he had “ongoing activation following viral infection” are erroneous.
Pet’r’s Ex. 26 at 2. There is simply no evidence that B.A.B. had any “immune dysregulation”
following his viral illness that occurred in January 2007.

        Next, Dr. Harum stated that B.A.B. had “presumed brain inflammation.” Pet’r’s Ex. 26
at 3. There is, however, no evidence of brain inflammation. The CBCs were reassuringly
normal. See Pet’r’s Exs. 6 at 21, 24, 25; 13 at 3.34 Physical and neurological examinations were
normal. Id. at 15. There is no foundation upon which Dr. Harum could base the presence of
brain inflammation at any time leading up to B.A.B.’s 12 month vacations, or even after them.

        Similarly, Dr. Harum used the phrases “neuronal inflammation,” “neuronal irritation,”
and “neuronal injury” to describe B.A.B.’s health prior to receipt of his 12 month vaccinations.
Pet’r’s Exs. 26 at 3; 29 at 6. She stated that the vaccines were “delivered at a vulnerable period
of immune dysregulation (discussed above) and neuronal35 inflammation.” Pet’r’s Ex. 26 at 3.
She also stated that the vaccines “independently elicit neuronal irritation, even doubling the risk
of seizures.” Id. Dr. Harum does not cite to any evidence in B.A.B.’s medical records, or
provide any supporting literature to provide a basis for her statements that B.A.B. had either
neuronal inflammation, seizures, or other injury. And as discussed above, the record lacks
evidence of either symptom manifestation or diagnosis of such an injury either before or after
B.A.B.’s 12 month vaccinations.

34
  Blood tests (CBCs) were performed on October 7, 2008, April 18, 2007, January 3, 2007, and
March 4, 2009, respectively. The results were mostly normal. The records do indicate decreased
levels of WBCs and granulocytes on January 3, 2007, but these levels returned to normal and
were normal on April 18, 2007, October 7, 2008, and March 4, 2009. Id.
35
  Neurons are classified as “any of the conducting cells of the nervous system. A typical neuron
consists of a cell body, containing the nucleus and the surrounding cytoplasm; several short
radiating processes; and one long process, which terminates in twiglike branches and may have
branches projecting along its course. The axon together with its covering or sheath forms the
nerve fiber.” DORLAND’S at 1267.

                                                 21
          The article cited by Dr. Harum to support her assertions regarding inflammation, Vargas,
et al.36, was discussed extensively in the OAP. The authors of that article “demonstrated a
marked increase in neuroglial responses, characterized by activation of the microglial and
astroglia in the brains of autistic patients.” Pet’r’s Ex. 27 at 24. They concluded that these
increases were “likely part of neuroinflammatory reactions.” Id.; see also Snyder, 2009 WL
332044 at, *87-88 (discussing Vargas). However, as the special masters in the OAP test case
indicated, the authors did not discuss whether they believed the neuroinflammation found was a
cause or effect of autism. See e.g., King, 2010 WL 892296 at, *40-41; Snyder, 2009 WL
332044, at *88. Moreover, there is no connection to or even the mention of a vaccine in the
article.

       The entire notion that BAB had some “identifiable predisposing conditions, such as
metabolic abnormalities or immune deficiencies” which would cause him to be susceptible to
increased microglial and astroglial activation from vaccines is wholly unsupported by the
medical records. Pet’r’s Ex. 29 at 5. Dr. Harum also concedes there is no evidence that B.A.B.
had any relevant genetic abnormality that would have affected his development. Id. at 5-6.

                             4. Dr. Harum’s Theory Part 4

       The next part of Dr. Harum’s medical theory is that B.A.B. “received a cluster of
vaccines that contributed further to microglial activation, overactive Th2 immunity, and
worsening encephalopathy.” Pet’r’s Ex. 26 at 3. She assumes that B.A.B. already had
microglial activation, overactive Th2 immunity, and encephalopathy. Dr. Harum does not define
microglial activation in her expert report, but she again references the article by Vargas, et al. to
support her broad assertions.37 However, in Vargas, the authors do not suggest that vaccines
cause or contribute to any microglial activation they found.

        Moreover, it is unclear what Dr. Harum means by referencing B.A.B.’s “overactive Th2
immunity,” as a component of her theory. Presumably, it ties into the aspect of her theory
related to the notion that B.A.B. had an abnormal immune response following his viral illness
which was worsened by the vaccines and played a role in causing or contributing to
encephalopathy. Throughout her reports, Dr. Harum suggests that B.A.B. may have an immune
dysregulation, immune incompetence, or that he may have suffered an “untoward immunologic
reaction.” Pet’r’s Ex. 26 at 3. She believes that B.A.B.’s abnormal granulocyte and lymphocyte
counts are evidence of his immune incompetence. Id.

       She also writes that B.A.B.’s “IgG total count was also high, suggesting excessive
immunoglobulin mediated inflammation (Th2 predominance).” Pet’r’s Exs. 26 at 2; 29 at 6.
The IgG test to which Dr. Harum references, however, was performed on September 29, 2008, a
year and a half after the vaccines were given. Dr. Harum provides no explanation for how that

 Vargas et al., “Neuroglial Activation and Neuroinflammation in the Brain of Patients with
36

Autism,” 57 ANN. NEUROL. 67-81 (2004) (filed as Pet’r’s Exs. 27 at 16-30; 28 at 111-25).
37
     See Vargas et al., supra note 34.

                                                 22
result, 18 months later, provides evidence of immune mediated inflammation that contributed to
autism or encephalopathy temporally associated with the vaccinations. She also cites an article
by Asherman, et al.,38 which examined the pro-inflammatory and anti-inflammatory
characteristics of IgG. See Pet’r’s Ex. 28 at 104-10. The authors devoted much of the discussion
to the anti-inflammatory aspects of IgG, theorizing that a better understanding of this aspect
“might enable us to replace this primary blood product [(IVIG)39] in the future with a
recombinant therapeutic.” Id. at 105.

       One other test relied upon by Dr. Harum is the IL-2 receptor Alpha, which was found to
be elevated on September 29, 2008, and March 4, 2009. Pet’r’s Ex. 9 at 10; Pet’r’s Ex. 13 at 1.
Dr. Harum states that these results suggest “immune system activation.” Pet’r’s Ex. 26 at 2.
Again, she does not explain how this fact supports her theory or provides evidence that B.A.B.
suffered a vaccine-related injury.

        Dr. Harum further cited an article by Triger, et al.40 for the proposition that “highly
elevated measles antibodies have been seen in a variety of clinical and autoimmune disorders,
characterized by excessive antibody production and inadequate innate immunity.” Pet’r’s Ex. 26
at 3. Examining groups of 21 to 6541 patients (depending on the disease involved), the authors
sought to determine if the elevated measles antibody titers reported in patients with chronic
active hepatitis could also be observed in patients with other diseases. Pet’r’s Ex. 28 at 126. The
authors found the same result in patients with other diseases, such as DLE,42 but not diseases
such as rheumatoid arthritis. Id. at 126, 131.43 This article, however, offers no support for Dr.
Harum’s assertions in this case.

        As stated earlier, B.A.B.’s elevated measles antibody titer following the MMRV
vaccination was characterized by Dr. Doreswamy as nothing more than “a good vaccine
response.” Pet’r’s Ex. 12 at 8. And even Dr. Harum seems to doubt her commitment to the
point that B.A.B.’s response to the measles vaccine was somehow evidence of immune

38
  Ascherman et al., “The Other Side of Immunoglobulin G: Suppressor of Inflammation,” 160
CLINIC. EXP. IMMUN. 161-67 (2010) (filed as Pet’r’s Ex. 28 at 104-10).
 39
   “IVIG” stands for intravenous immunoglobulin. Neil M. Davis, MEDICAL ABBREVIATIONS,
15th Edition, at 178 (2011).
40
  Triger et al., “Measles Antibodies and Autoantibodies in Autoimmune Disorders,” 24 CLIN.
EXP. IMMUNOL. 407-14 (1976) (filed as Pet’r’s Ex. 28 at 126-33).
41
   The total for the group of patients with rheumatoid arthritis is listed as 55 at one point and 65
at another. Compare Pet’r’s Ex. 28 at 126 with id. at 128 (total listed in table).
42
  The authors of this article do not provide the disease labeled as DLE but it appears to stand for
discoid lupus erythematosus, “a chronic form of cutaneous lupus erythematosus.” DORLAND’S at
1079.
43
   The authors acknowledged their result with regard to rheumatoid arthritis differed from other
studies but argued those studies were not comparable. Pet’r’s Ex. 28 at 131.

                                                 23
incompetence when she says, “[w]hile . . . robust antibody production against the vaccine strain
of measles is good, it may also contribute to ongoing inflammation of the brain . . . .” Pet’r’s Ex.
26 at 3. The word “may” in this context is weak when compared with the balance of Dr.
Harum’s opinions. In her third report, Dr. Harum finally conceded that B.A.B.’s “antibody
response to measles was normal.” Pet’r’s Ex. 29 at 7.

        The last phase of this part of Dr. Harum’s theory is that B.A.B. “received a cluster of
vaccines that contributed further to . . . worsening encephalopathy.” Pet’r’s Ex. 26 at 3. The
lack of evidence to support any conclusion that B.A.B. had encephalopathy has been previously
discussed. Here, however, Dr. Harum implies that B.A.B.’s condition is worsening, and again,
she fails to cite to any medical records to provide a basis for this characterization.

                             5. Dr. Harum’s Theory Part 5

        The last aspect of Dr. Harum’s medical theory is that the vaccines further contributed to
“this injury pathway through the load of aluminum, glutamate, formaldehyde and unidentified
pathogens.” 44 Pet’r’s Exs. 26 at 3; 29 at 8. Dr. Harum stated that B.A.B. received “225 mcg in
the PedVax and 125 mcg in [the] Proquad” vaccines, for “a total of 350 mcg aluminum.” Pet’r’s
Ex. 29 at 8. Dr. Harum further stated that the “FDA recommends no more than 25 mcg of
aluminum per day, when parenterally delivered.” Id. However, Dr. Harum provided no citation
for her assertion, nor did she discuss the potential effect that the alleged larger dose of aluminum
in B.A.B.’s vaccinations could have had on his development.

         Furthermore, Dr. Harum opined that in the context of the C677T MTHFR mutation, “the
aluminum may have presented an additional aggravating factor.” Pet’r’s Ex. 29 at 8. She states
generally that “vaccines can contribute further to this pathway of injury through the load of
aluminum, glutamate, formaldehyde and unidentified pathogens.” Id. She does not, however,
explain how the aluminum may have been an aggravating factor, nor does she provide any
evidence that the vaccinations B.A.B. received contained aluminum, glutamate, formaldehyde, or
other unidentified pathogens. And even if B.A.B.’s vaccinations contained all of these alleged
ingredients, Dr. Harum failed to show how they could have caused B.A.B. to develop
encephalopathy. She cites two articles, one by Campbell et al. 45 and another by Giangaspero et
al.46 to support her generalizations, neither of which is relevant to B.A.B.’s case.

       The Campbell researchers discuss the links between exposure to aluminum and the
development of age-related neurological disorders, mainly focusing on Alzheimer’s disease
(“AD”). Pet’r’s Ex. 28 at 40. Acknowledging that “epidemiological studies show that long-term

44
  To support her assertion, Dr. Harum cited Campbell et al., “Chronic Exposure to Aluminum in
Drinking Water Increases Inflammatory Parameters Selectively in the Brain,” 75 J. NEUROSCI.
RES. 565-72 (2004) (filed as Pet’r’s Ex. 28 at 40-47).
45
     Campbell et al., supra note 42 at 565-72.
46
  Giangaspero et al., “Genotypes of Pestivirus RNA Detected in Live Virus Vaccines for Human
Use,” 63 J. VET. MED. SCI. 723-33 (2001) (abstract only filed as Pet’r’s Ex. 28 at 134).

                                                 24
exposure to [aluminum] is necessary for adverse health effects,” they exposed mice to levels of
aluminum in drinking water for ten weeks, a period comparable to eight years for humans. Id. at
42. Although the activation of transcription factors (one of the initial steps of an inflammatory
response) was found at the lowest levels of aluminum (comparable to levels found in certain
areas of Canada), values associated with inflammation “reached significance only at the higher
[levels of aluminum] exposures).” Id. at 43. The researchers cautioned that “it is possible that a
threshold concentration of the metal has to be accumulated in the brain before an inflammatory
response is even initiated.” Id. at 43-44. Furthermore, they theorized that the “[i]nflammatory
processes . . . within the aging brain . . . may provide the substrate upon which aluminum can act
and thus accelerate the progression of age-related neurodegenerative disease.” Id. at 44
(emphasis added). They concluded only that aluminum “could contribute to progressions of
neurodegeneration.” Id. at 40.

        The authors of the Campbell study state, “Abnormal neurological symptoms have been
observed in several patients receiving intramuscular injections of [aluminum]-containing
vaccines,” and “the [World Health Organization] Vaccine Safety Advisory Committee has
recognized that there may be a subset of predisposed individuals who are sensitive to
[aluminum]-containing adjuvant.” Pet’r’s Ex. 28 at 40 (internal citations omitted) (emphasis
added). However, the authors do not reach any other conclusions. Vaccines are mentioned only
briefly to provide support for the proposition that aluminum potassium sulfate is an adjuvant that
“enhance[s] the systematic immune response.” Id. at 44.

       Dr. Harum does not suggest, and the record does not indicate, that B.A.B. was exposed to
aluminum over a period of weeks or years. Moreover, B.A.B. is not elderly and Dr. Harum does
not explain or suggest that B.A.B. is a “predisposed individual [] who [is] sensitive to
[aluminum]-containing adjuvant.” Pet’r’s Ex. 28 at 40. While Dr. Harum postulates that the
alleged high levels of aluminum found in the Proquad vaccines could have led B.A.B. to
experience an “inflammatory event” such as an encephalopathy, the Campbell study and its
findings are focused on long-term aluminum exposure through drinking water. Thus, the
undersigned finds the Campbell article inapplicable to B.A.B.’s case.

        Dr. Harum’s cite to the Giangaspero study47 is also not persuasive evidence that B.A.B.
suffered an encephalopathy, and the undersigned struggles to see how it is relevant to B.A.B.’s
case at all. The researchers tested 33 different live virus vaccines for human use48 for the
presence of pestivirus49 and found that “[f]ive (13.1%) out of 38 tested samples were positive for


47
  The undersigned notes that petitioner did not file the full Giangaspero article but rather only a
one page abstract. See Pet’r’s Ex. 28 at 134.
48
  The vaccines tested included “29 monovalent vaccines against measles, mumps, rubella or
polio, eight polyvalent vaccines against measles-mumps-rubella and one bacterial polyvalent
vaccine against Streptococcus pneumoniae.” Pet’r’s Ex. 28 at 134.
49
  Pestivirus is “a genus of viruses of the family Flaviviridae comprising bovine diarrhea virus,
hog cholera virus, and border disease virus of sheep. DORLAND’S at 1421-22.

                                                25
pestivirus RNA.” Pet’r’s Ex. 28 at 134. According to the researchers, “[t]hese findings indicate
that contamination by animal pestivirus may occur in biological products for human use.” Id.

        Presumably, petitioner introduced the Giangaspero article to show the potential for
human vaccines to be contaminated. Assuming, arguendo, that contaminants were present in the
vaccinations that B.A.B. received, Dr. Harum offers no explanation as to how these potential
contaminants, including pestivirus, could have caused B.A.B. to develop encephalopathy. The
abstract of the Giangaspero article that petitioner filed, without further explanation from Dr.
Harum or petitioner, seems to be irrelevant to B.A.B.’s alleged development of encephalopathy.

        Considering Dr. Harum’s theory on the whole reveals a fundamental flaw: in her second
report, she notes that there is evidence of loss of skills, language plateau, auditory awareness and
visual attention after B.A.B.’s 12-month vaccinations. Pet’r’s Ex. 26 at 1. However, the medical
records demonstrate that B.A.B. did not begin to lose any skills until approximately 18 months of
age, when petitioner first expressed concern to the pediatrician during an office visit on October
19, 2007. Pet’r’s Ex. 6 at 4, 16. Moreover, at B.A.B.’s nine, 12, and 18-month well-child visits,
he was noted to be a well-child and to have met all developmental milestones. Pet’r’s Ex. 6 at
14-16. As for the abnormalities seen by Dr. Harum on September 26, 2008, when B.A.B. was 29
months old, including “reduced eye contact, limited cooperation with balance maneuvers,
frequent tripping, [] intermittent toe walking … [and] oral aversion,” Dr. Harum concedes that
these physical findings “do not specifically relate to vaccination at 12 months of age, nor do they
confirm regression of any sort.” Pet’r’s Ex. 29 at 7.

        In addition to the issues with Dr. Harum’s expert reports noted above, the undersigned
notes several other problems. Dr. Harum fails to explain how subclinical encephalopathy would
more likely result from the MMRV vaccine than from the viral illnesses accompanied by fever
and other symptoms that B.A.B. experienced two to three months before the MMRV vaccine or
four months after it. She makes vague references to vitamin, iron and folate deficiencies, “if
present at the time of vaccine complications,” as possible contributors to B.A.B.’s poor immune
response. Pet’r’s Ex. 19 at 1. However, the record reflects that B.A.B. did not experience such
deficiencies, nor did he have a poor immune response to the MMRV vaccine. In fact, his
pediatrician noted that he had a robust response to the measles portion. Dr. Harum refers to
vaccine-caused seizures, but B.A.B. has never been diagnosed with a seizure disorder,50 much
less one temporally related to a vaccination.

        Likewise, Dr. Harum makes vague references to markers of “oxidized DNA and reduced
glutathione stores” and data which “suggest oxidized molecules are elevated” when B.A.B. was
29 months of age, but she does not explain how vaccines given at 12 months of age relate to
these findings, or that these findings prove a vaccine related injury. See Pet’r’s Ex. 29 at 6.

50
  While B.A.B.’s parents expressed concerns about seizures, no doctor ever diagnosed him as
having had one. Dr. Harum also admits that B.A.B. never experienced even one seizure. Pet’r’s
Ex. 26 at 3. In her third report, Dr. Harum does clarify her position on several important issues.
B.A.B.’s parents describe “spells,” which were temporally associated with his 12 month
vaccines. Pet’r’s Ex. 29 at 7. Dr. Harum concedes, however, that these spells did not constitute
seizures and that B.A.B. “clearly does not have a seizure disorder.” Id.

                                                26
           b. Respondent’s Expert, Dr. Gregory L. Holmes

        Dr. Gregory Holmes testified on behalf of respondent. Dr. Holmes received his medical
degree from Washington and Lee University, and he holds an honorary degree from Harvard.
Resp’s Ex. C at 1. He did an internship in pediatrics and completed his residency in pediatrics at
the Yale University School of Medicine, after which he completed another residency in
Neurology at the University of Virginia School of Medicine. Id. He is certified by the American
Board of Pediatrics, the American Board of Psychiatry and Neurology with Special Competence
in Child Neurology, and the American Board of Clinical Neurophysiology. Id. Dr. Holmes has
also held various academic appointments, including his current positions as a professor of
pediatrics at the University of Vermont College of Medicine and the professor and chair of the
neurology and pediatrics department at Dartmouth Medical School. Id. at 2. He has received
numerous academic and fellowship awards, and he has served as an editor for over a dozen
pediatric and neurology medical journals. Id. at 5-7. In addition, he has published numerous
medical articles on topics ranging from pediatric seizures to brain development and behavior. Id.
at 39-65.

        Dr. Holmes set forth a lengthy overview of B.A.B.’s medical history and clinical course,
concluding that B.A.B. is an “eight year old boy with the diagnosis of autistic spectrum disorder
(ASD) and language delay. His clinical history and neurological examination are quite
consistent with this diagnosis.” Resp’s Ex. B at 7.51

         As for Dr. Harum’s conclusion that B.A.B. sustained encephalopathy, Dr. Holmes
disagreed. Dr. Holmes defined encephalopathy as a “general term used to describe brain
dysfunction.” Resp’s Ex. B at 7. He explains that the “clinical features” of encephalopathy
include “a change in mental status, ranging from confusion to stupor or coma, alterations in
muscle tone, abnormal movements or severe seizures.” Id. Examples of encephalopathy set
forth in the IOM include “encephalitis, meningitis, seizures and head trauma, none of which
were suffered by [B.A.B.].” Id. Moreover, B.A.B.’s pediatrician saw him three times following
the vaccinations at issue (July 14, August 15, and September 17), and in the records of those
visits, “there is no mention of any behavior consistent with an encephalopathy.” Id. at 7.

        Dr. Holmes summarized, “The report of Dr. Harum does not dissuade me from my
original opinion. There is no evidence in the medical record to indicate that [B.A.B.] suffered
from an acute or subacute encephalopathy.” Resp’s Ex. Q at 4. He further stated, “[B.A.B.] has
autistic spectrum disorder and the MMR vaccine has no bearing on his current clinical condition.
Dr. Harum has provided no reliable evidence linking the MMR vaccine to autism.” Id. As
explained in further detail below, the undersigned finds Dr. Holmes’ opinions to be more
persuasive than those of Dr. Harum.

     V.    Encephalitis vs. Encephalopathy vs. Subacute/Subclinical Encephalopathy

        To provide further clarity to the discussion of the Althen prongs, the undersigned first
notes the differences between encephalitis and encephalopathy. Encephalitis is defined as

51
  It should be noted that respondent’s Exhibit B was filed twice, once on December 17, 2014
(ECF No. 65) and again on January 7, 2015 (ECF No. 66).
                                               27
“inflammation of the brain.”52 In contrast, encephalopathy is defined as “any degenerative
disease of the brain.”53 Dr. Harum conflates these terms throughout her expert reports, despite
the fact that they represent two distinct diagnoses. For example, in her first expert report, Dr.
Harum states, “. . . there is a plausible body of evidence to associate MMR and other vaccines
and encephalitis resulting in mental retardation and speech impairment.” Pet’r’s Ex. 19 at 2.
From this assertion, she concludes that “one can postulate that there is a plausible association
between MMR and other vaccines and subacute encephalopathy associated with developmental
regression.” Id. (emphasis added). While Dr. Harum is correct that the MMR vaccination has
been known to cause acute encephalopathy in children five to 15 days post vaccination,54 it is
incorrect to assume that therefore there is a relationship between MMRV and “subtle” or
subacute encephalopathy, as described by. Dr. Harum.55

        While Dr. Harum eventually concludes that B.A.B. did not suffer from encephalitis and
only from encephalopathy, the central component of her theory is that B.A.B. suffered from a
“subacute” or “subclinical” encephalopathy. Dr. Harum describes B.A.B.’s condition as
subacute or subclinical “because it was not acute and was subtle enough for parents to recognize,
but not obvious enough for the pediatrician to be concerned about or to inhibit ridicule of Mom’s
internet research.” Pet’r’s Ex. 29 at 4. She believes that B.A.B.’s “developmental plateau . . . .
suggests a subacute encephalopathy.” Pet’r’s Ex. 26 at 4. Despite the fact that none of B.A.B.’s
treating physicians ever suggested a diagnosis of encephalopathy, Dr. Harum presumes that
B.A.B. suffered “subclinical encephalopathy,” which went unnoticed by his physicians during
numerous doctor’s appointments over a period of several months.

52
     DORLAND’S at 612.
53
     DORLAND’S at 614.
54
  While petitioner has not alleged that B.A.B. suffered a Table encephalopathy, it is important to
note that “encephalopathy” does exist as a Table injury for several vaccinations, including
pertussis or measles containing vaccines. However, the Table specifies a lengthy and precise
definition of an “encephalopathy.” See 42 C.F.R. § 100.3(b)(2). To summarize, the regulation
requires a “significantly decreased level of consciousness” that lasts at least 24 hours, which was
not seen in B.A.B.’s case. As former Chief Special Master Campbell-Smith noted in Waddell v.
Sec’y of Health & Human Servs., No. 10-316V, 2012 WL 4829291, at *6 (Fed. Cl. Spec. Mstr.
Sept. 19, 2012), the symptoms of a Table Injury encephalopathy are not “subtle.”
55
  It should also be noted that Dr. Harum does not give a citation to a definition of subacute or
subclinical encephalopathy. Furthermore, Dr. Holmes noted:

         The pathophysiological mechanisms by which such a “subtle encephalopathy”
         could result in autism spectrum disorder is not discussed by Dr. Harum. The term
         “subtle encephalopathy” is not a medically recognized entity and it is difficult to
         understand how such a subtle process could result in harm. It is highly unlikely
         that a vaccine-induced encephalopathy could be so subtle that it was not noted by
         the pediatrician.

Resp’s Ex. Q at 3.
                                                 28
   VI.     Petitioner has Failed the Althen Test

       In Althen, the United States Court of Appeals for the Federal Circuit discussed the issue
of “causation-in-fact” in Vaccine Act cases. The court stated:

   [Petitioner’s] burden is to show by preponderant evidence that the vaccination brought about
   [the child’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 the
   vaccination and injury. If [petitioner] satisfies this burden, she is entitled to recover unless
   the [government] shows, also by a preponderance of the evidence, that the injury was in fact
   caused by factors unrelated to the vaccine.

Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005) (internal
citations and quotations omitted). In the pages above, the undersigned has provided a detailed
explanation of how petitioner has failed to demonstrate preponderant evidence of “causation-in-
fact.” The next section shows how that analysis fits within the three prongs of the Althen test.
For the reasons set forth below, the undersigned finds that petitioner has failed to satisfy the
Althen test and is therefore not entitled to compensation.

               A. Althen Prong One: Lack of a Reliable Medical Theory

        As discussed below, petitioner has failed Prong One of Althen for three reasons. First,
the record lacks evidence to show that Proquad can cause encephalopathy or sub-clinical
encephalopathy, as described by Dr. Harum. Second, Dr. Harum mischaracterizes B.A.B.’s
diagnosis as an encephalopathy despite the fact that he was clearly diagnosed with ASD.
Finally, Dr. Harum’s medical theory bears a striking resemblance to the theory proposed by Dr.
Marcel Kinsbourne during the OAP, which was found unpersuasive in all three test cases.

                       a. Lack of Evidence Demonstrating that Proquad can Cause
                          Encephalopathy or “SubClinical” Encephalopathy

        Prong One of Althen requires petitioner to show by preponderant evidence a medical
theory of how the MMRV vaccination B.A.B. received on April 18, 2007, can cause
encephalopathy. As discussed above, however, Dr. Harum has not demonstrated that the
Proquad vaccine can cause encephalopathy. Instead, Dr. Harum has conflated the definitions of
encephalitis and encephalopathy and has presented a number of claims and statements in her
expert reports which lack foundation.

                       b. Mischaracterization of B.A.B.’s ASD Diagnosis as a “Subclinical”
                          Encephalopathy

        In denying petitioner’s earlier motion for interim fees and costs, former Chief Special
Master Vowell noted that after the OAP proceedings, some petitioners chose, in spite of an ASD
diagnosis, to pursue their cases by characterizing their children’s injuries as “encephalopathy” or
seizure disorders accompanied by developmental delay, among others. Former Chief Special
Master Vowell observed that petitioners often chose to amend their theories “based on a belief
                                                29
that claims alleging autism [would] not be compensated, but that claims alleging these other
conditions may be compensated.” Fester v. Sec’y of Health & Human Servs., No. 10-243V,
2013 WL 5367670, at 1 n.5 (Fed. Cl. Spec. Mstr. Aug. 27, 2013). She further stated, “[R]e-
characterizing a condition as an “encephalopathy”—a term that can encompass conditions
ranging from intoxication to a coma—when another diagnosis is more specific and appropriate
does little to advance a vaccine injury claim.” Id.56

         Not only does Dr. Harum conflate encephalopathy and encephalitis, but she has offered
no support for her proposed theories of causation. Although not required to provide medical
literature to support her theory, the medical literature Dr. Harum has cited provides no support.
See Andreu ex rel. Andreu v. Sec’y of Health & Human Servs., 569 F.3d. 1367, 1378-79 (Fed.
Cir. 2009) (explaining that “requiring ‘objective confirmation’ in the medical literature prevents
the use of circumstantial evidence … and negates the system created by Congress through the
Vaccine Act” (internal citations omitted)). However, Dr. Harum is still required to prove her
theory by preponderant evidence, which she has failed to do.




56
   Though the issue of causation was not adjudicated, former Chief Special Master Campbell-
Smith explained in Poling v. Sec’y of Health & Human Servs., No. 02-1466V, 2011 WL 678559
(Fed. Cl. Spec. Mstr. Jan. 28, 2011), that petitioners received compensation because the child
suffered a Table Injury, specifically a Table encephalopathy, and not because respondent
conceded or the special master found that the child’s ASD was either caused or significantly
aggravated by a vaccination. Similarly, in Wright v. Sec’y of Health & Human Servs., No.12-
423V, 2015 WL 6665600, at *30 (Fed. Cl. Spec. Mstr. Sept. 21, 2015), former Chief Special
Master Vowell found that a child who was later found to have ASD suffered a Table Injury
(encephalopathy) after receiving a vaccination. In finding that petitioner was entitled to
compensation, however, Special Master Vowell emphasized that she was not finding that the
child’s ASD was “caused-in-fact” by the vaccination, even remarking that petitioner’s medical
theory of causation was “absurd.” See Sturdivant, 2016 WL 552529, at *5, note 4.

        As Special Master Hastings has noted, the compensation of the petitioners in Poling and
Wright “does not afford any support to the notion that vaccinations can contribute to the
causation of autism …. Congress forthrightly acknowledged that the Table Injury presumptions
would result in compensation for some injuries that were not, in fact, truly vaccine caused.”
Sturdivant v. Sec’y of Health & Human Servs., No. 07-788V,
http://www.help.senate.gov/hearings/s-2700-s185-s2713-s_-nih-strategic-plan-and-inclusion-in-
clinical-research-and-s_-promoting-biomedical-research-and-public-health-for-patients-act, 2016
WL 552529, at *5 n.4 (Fed. Cl. Spec. Mstr. Jan 21, 2016)(emphasis in original). In this case,
petitioner has made clear that although B.A.B. suffers from ASD, her medical theory is that
B.A.B developed encephalopathy from the Proquad vaccination, which subsequently caused him
to develop a serious brain injury and developmental delay. Whether characterized as autism or
encephalopathy, petitioner still has to prove that B.A.B.’s injury was “caused-in-fact” by the
Proquad vaccination, and this she has not done.

                                                30
                      c. Dr. Harum’s Medical Theory of Causation is Similar to the
                         Earlier Proposed Theory of Dr. Marcel Kinsbourne

        In addition to being unable to articulate a reliable medical theory tending to show that
MMRV can cause encephalopathy, the undersigned further notes that certain parts of Dr.
Harum’s theory are remarkably similar to the theory and testimony of Dr. Kinsbourne, as given
in Snyder, 2009 WL 332044, which was part of the OAP. Dr. Kinsbourne was the leading expert
witness for petitioners in the Theory 1 test cases.57 “Dr. Kinsbourne’s role was to provide the
theory or theories to explain how measles virus could, directly or indirectly, cause at least some
cases of ASD.” Snyder, 2009 WL 332044, at *87. Dr. Kinsbourne offered two overarching
theories to explain how the measles virus could lead to the development of ASD. Id. Special
Master Vowell explained, “The first theory was that the virus caused an inflammatory process in
the brain leading to an encephalopathy. The second theory, built in some measure on the first,
relied on persistent measles virus causing inflammatory damage to cells, leading to an imbalance
in the excitation-inhibition chemicals in the brain.” Id.

        Dr. Kinsbourne’s theory was divided into three core stages. Stage One occurred as the
brain’s innate immune system caused neuroinflammation, mediated by microglial activation,
which in turn caused the release of cytokines and damaged astrocytes. As a result of damage to
the astrocytes, brain glutamate levels rose. Snyder, 2009 WL 332044, at *87. In Stage Two, the
excess glutamate in the brain caused over-arousal or over-activation of the brain, which then
caused the potential for seizures and neuronal death as the result of excitotoxicity. Id. In Stage
Three, Dr. Kinsbourne hypothesized that “[n]eural activation and over-arousal could account for
autistic behavior.” Id.

       Dr. Harum’s theory bears a striking resemblance to Dr. Kinsbourne’s three tiered theory,
which was found to contain no persuasive evidence that the MMR vaccine contributed in any
way to cause ASD. For example, Dr. Harum opines:

       These mechanisms of injury contribute to [B.A.B.’s] autism spectrum condition
       through an increase in brain inflammation, a pathophysiologic mechanism well
       described in spectrum disorders. This mechanism converges onto the more
       recently described neuronal pathways and signaling systems identified as


57
  The Petitioners’ Steering Committee (“PSC”), formed in 2002 by petitioners’ attorneys in the
Vaccine Program, presented two separate theories in the OAP regarding how vaccines cause
ASD. “The first theory alleged that the measles portion of the measles, mumps, rubella
(“MMR”) vaccine could cause ASDs. That theory was presented in three separate Program test
cases during several weeks of trial in 2007.” Sturdivant, 2016 WL 552529, at *3 (emphasis in
original). In all those cases, the special masters rejected petitioners’ theory of causation. See
Cedillo, 2009 WL 331968; Hazlehurst v. Sec’y of Health & Human Servs., 03-645V, 2009 WL
332306 (Fed. Cl. Spec. Mstr. Feb. 12, 2009), aff’d, 88 Fed. Cl. 473 (2009), aff’d, 604 F.3d 1343
(Fed. Cir. 2010); Snyder, 2009 WL 332044.



                                                31
       impaired in autism by virtue of over activity of the glutamate receptors and
       excitetoxicity [sic] to developing synapses.

Pet’r’s Ex. 26 at 3 (emphasis added). Dr. Harum also states, “The evidence that immune
deregulation is associated with an autism diagnosis lies in the landmark data that points
toward chronic inflammation in autism. The [Vargas] authors demonstrated long-term
microglial activation and abnormally high cytokine levels.” Id. at 2 (emphasis added).

        It appears from these and other similar statements that Dr. Harum simply borrows
and enhances certain aspects of Dr. Kinsbourne’s earlier theory in an effort to opine that
the Proquad vaccine could cause encephalopathy and eventually lead to neuronal damage.
However, Dr. Harum, like Dr. Kinsbourne, has failed to demonstrate a reliable theory
demonstrating that MMR can cause subacute encephalopathy. Dr. Kinsbourne’s theory
was ultimately rejected in the three tests cases. See Cedillo, 2009 WL 331968;
Hazlehurst, 2009 WL 332306; Snyder, 2009 WL 332044. So too, the undersigned rejects
Dr. Harum’s similar reasoning in this case.

       For all of the reasons stated above, petitioner has failed to provide evidence of
causation sufficient to meet Prong One of Althen.

               B. Althen Prong Two: Lack of a Logical Sequence of Cause and Effect

       Althen Prong Two requires petitioner to show by preponderant evidence a logical
sequence of cause and effect to explain how the MMRV vaccination caused B.A.B. to develop
encephalopathy. As explained above, the medical records are devoid of any evidence that
B.A.B. ever developed or was diagnosed with encephalopathy. Moreover, Dr. Harum’s three
medical expert reports do not clearly or logically delineate facts to show that B.A.B. developed
encephalopathy, much less that the MMRV vaccine actually caused this alleged encephalopathy.

       Dr. Harum also relies upon factual inaccuracies and medical presumptions which are not
supported by B.A.B.’s medical records. For example, the first step of Dr. Harum’s theory of
causation is that B.A.B. suffered from roseola infantum at the age of nine months. See Pet’r’s
Ex. 29 at 8; Pet’r’s Ex. 26 at 3. However, it is clear from the record that B.A.B. was not
diagnosed with roseola infantum until the age of 22 months, which was 10 months after he
received the Proquad vaccine. Dr. Harum did not become B.A.B.’s treating physician until he
was 29 months old, and thus her medical opinion is based on B.A.B.’s pediatric records. These
records do not indicate that B.A.B. suffered from roseola infantum prior to the age of 22 months,
and B.A.B.’s treating physicians did not ever consider the diagnosis until that time.

        Additionally, despite Dr. Harum’s contention that the vaccines were given in proximity to
a “significant encephalitic virus infection” or a “mild and temporary encephalitis,” there are no
records or notes from any of B.A.B.’s doctors regarding a condition or diagnosis, despite the fact
that B.A.B. visited his pediatrician a number of times while he ostensibly suffered from the
condition. Pet’r’s Ex. 26 at 3; Pet’r’s Ex. 29 at 3. The assertion that B.A.B. suffered from a
subacute encephalopathy that went undetected and untreated by pediatricians for several months
is unfounded. The undersigned further notes that no previous Program cases have awarded
compensation to petitioners based on a diagnosis of subacute or subclinical encephalopathy.
                                                32
        Dr. Harum suggests that B.A.B.’s lab results are evidence of an apparent, undetected
encephalopathy. She points to B.A.B.’s granular leukocyte count, elevated NSE levels,
abnormal IgG count, and Il-2 Receptor Alpha elevation to support these assertions. She follows
her discussion of these lab results with citations to a number of medical articles that supposedly
support her contention that B.A.B. suffered from encephalopathy. However, Dr. Harum does not
actually explain how their findings are applicable to B.A.B.’s case and/or discuss how they
provide evidence that he suffered an encephalopathy.

        Upon further examination of the medical articles cited by Dr. Harum, most are irrelevant
to B.A.B.’s diagnosis of ASD and a few actually contradict her opinions altogether. For
example, as discussed above, Dr. Harum’s citation to the Berger58 study actually disproves her
theory that B.A.B.’s elevated NSE levels point to “ongoing neuronal injury” and encephalopathy.
According to the Berger study, if B.A.B. had suffered from an inflicted TBI, one would expect
his NSE levels to peak up to eight days after the injury. The study’s findings suggest that
B.A.B.’s elevated NSE levels on September 29, 2008, were the result of a much more recent
injury than his April 18, 2007 Proquad vaccination.

       Dr. Harum’s second and third medical expert reports adapt a “kitchen sink approach” of
including all potential medical theories, such as the theory that “the load of aluminum,
glutamate, formaldehyde and unidentified pathogens” presumably contributed to B.A.B.’s
development of encephalopathy. See Pet’r’s Ex. 26 at 3; Pet’r’s Ex. 29 at 8. Dr. Harum seems
to suggest that the amount of aluminum found in the PedVax and the Proquad vaccines
contributed to the alleged development of encephalopathy. However, petitioner contends that the
Proquad vaccine, not PedVax, caused B.A.B.’s encephalopathy. Petition at Preamble.
Moreover, the articles cited by Dr. Harum do not support her assertion that foreign contaminants
found in vaccines contribute to neurological injuries. Dr. Harum merely cites these studies and
does not provide any explanation as to how or why they are applicable to B.A.B.’s case.

       Thus, petitioner has failed to provide preponderant evidence of actual causation under
Althen Prong Two.

                 C. Althen Prong Three: Lack of a Temporal Relationship

        Under Prong Three of Althen, petitioner must show by preponderant evidence B.A.B.’s
encephalopathy occurred within a time frame that is medically appropriate for the alleged
mechanism of harm. See Pafford, 451 F.3d 1352, 1358 (Fed. Cir. 2006) (“Evidence
demonstrating petitioner’s injury occurred within a medically acceptable time frame bolsters a
link between the injury alleged and the vaccination at issue under the ‘but-for’ prong of the
causation analysis.”). As the undersigned has already explained, Dr. Harum did not offer
sufficient evidence tending to show that the Proquad vaccination causes encephalopathy, much
less that B.A.B. developed an encephalopathy from the Proquad vaccination. It follows, then,
that petitioner cannot prove Prong Three of Althen.


58
     Berger et al., 109 PEDIATRICS E31 (2002) (filed as Pet’r’s Ex 27 at 1-8).

                                                  33
        Even if Dr. Harum had shown that B.A.B. developed encephalopathy after receiving the
MMRV vaccination, Dr. Harum does not provide preponderant evidence of a temporal
relationship between the vaccine and B.A.B.’s alleged encephalopathy. Dr. Harum does not
address the issue of a proximate temporal relationship between Proquad and encephalopathy
other than to note the IOM’s conclusion that the measles vaccine “can cause measles inclusion
body encephalitis [not encephalopathy] due to the vaccine strain of measles, after administration
of the measles vaccine, particularly in immune compromised individuals up to nine months after
the vaccine administration.” IOM at 110 (emphasis added); see also Pet’r’s Ex. 26 at 1. Apart
from this assertion, Dr. Harum does not offer any medical theory showing a proximate temporal
relationship between B.A.B.’s vaccination and his alleged encephalopathy. Therefore, petitioner
has failed to prove Prong Three of Althen.

   VII.    Conclusion

        For the reasons discussed above, the undersigned finds that petitioner has not established
entitlement to compensation and her petition must be dismissed. Therefore, this case is
dismissed for insufficient proof. The Clerk shall enter judgment accordingly.

       IT IS SO ORDERED.

                                                     s/ Nora Beth Dorsey
                                                     Nora Beth Dorsey
                                                     Chief Special Master




                                                34
