                  In the United States Court of Federal Claims
                                      OFFICE OF SPECIAL MASTERS
                                              No. 12-312V


*************************
K.L.,                       *
                            *                                               Filed: March 17, 2017
                Petitioner, *
                            *                                               Special Master Corcoran
          v.                *
                            *
SECRETARY OF HEALTH AND     *                                               Decision; Human Papillomavirus
HUMAN SERVICES,             *                                               (“HPV”); Epilepsy; Seizures;
                            *                                               Cytokines.
               Respondent.  *
                            *
*************************

Paul Dannenberg, Huntington, VT, for Petitioner.

Robert Paul Coleman, U.S. Dep’t of Justice, Washington, DC, for Respondent.


                            DECISION DENYING ENTITLEMENT1
        On May 11, 2012, K.L. filed this action seeking compensation under the National Vaccine
Injury Compensation Program (the “Vaccine Program”2). Petition (“Pet.”), dated May 11, 2012
(ECF No. 1); Amended Pet., dated Mar. 11, 2013 (ECF No. 24). Petitioner alleges that she suffered
a variety of injuries (including partial onset epilepsy, seizures, and migraine headaches) as a result
of the human papillomavirus (“HPV”) vaccine she received in February 2010. Amended Pet. at 1.



t
 This decision will be posted on the United States Court of Federal Claims’ website, in accordance with the E-
Government Act of 2002, Pub. L. No. 107-347, § 205, 116 Stat. 2899, 2913 (codified as amended, 44 U.S.C. § 3501
note (2006)). As provided by 42 U.S.C. § 300aa-12(d)(4)(B), however, the parties may object to the published ruling’s
inclusion of certain kinds of confidential information. Specifically, under Vaccine Rule 18(b), each party has fourteen
(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). Otherwise,
the entire decision will be available to the public in its current form. Id.
2
 The Vaccine Program comprises Part 2 of the National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660,
100 Stat. 3758 (codified as amended, 42 U.S.C. §§ 300aa-10 to 34 (2006)) [hereinafter “Vaccine Act” or “the Act”].
All subsequent references to sections of the Vaccine Act shall be to the pertinent subparagraph of 42 U.S.C. § 300aa
(2006).
        After considering the record as a whole, and for the reasons explained below, I find that
Petitioner has failed to carry her burden in establishing causation, and therefore is not entitled to
compensation under the Vaccine Program.

    I.        FACTUAL BACKGROUND

         Early History and HPV Vaccinations

        K.L. (born March 25, 1993) was a relatively healthy child for most of her early life.
Throughout her childhood, however, she had recurring otitis media3, anxiety disorder, reading
difficulties, and a vasovagal attack with syncope.4 Ex. 3 at 27-28, 34, 40-41, 145. In addition, K.L.
has some family history of seizures, including three cousins on her father’s side who experienced
seizures at early ages—one of whom was formally diagnosed with epilepsy. Ex. 6 at 8. K.L.’s
father had also once experienced a seizure after sleep deprivation. Ex. 3 at 150.

         Petitioner routinely went to her primary care physician for yearly check-ups. At one such
check-up on May 18, 2009, she received the first dose of the HPV vaccine, when she was 16. Ex.
2 at 1. She thereafter received the second and third doses of the HPV vaccine on August 18, 2009,
and February 9, 2010, respectively. Ex. 2 at 4. The filed medical records reveal no complications
or reactions to the first or second doses.

         Onset of Seizures

        On February 11, 2010 - two days after her third HPV vaccine dose - K.L. was transported
by ambulance to the Copley Emergency Room (“ER”) in Morrisville, Vermont, because of seizure
activity and subsequent decreased mental status. Ex. 3 at 107. K.L.’s mother reported that before
the seizure occurred she noticed K.L. having fine motor twitches in her right hand, followed shortly
(within five minutes) by K.L. slumping over and hitting her head on a door handle. Id. K.L.’s
mother then stated that she helped K.L. to the ground where “she had foaming at the mouth, was
biting her tongue, and was somewhat blue around the mouth. This lasted about 4 minutes.” Id.
When the ambulance arrived a few minutes later, K.L. was conscious but confused, and had
difficulty seeing what was in front of her. Id. Nonetheless, K.L. was able to help get herself onto
the ambulance stretcher and was driven to Copley ER for evaluation, where she complained of a
headache. Id.

3
 This recurrent condition resulted in K.L. having Sheehy PE tubes placed in her ears when she was about two and
one-half years old (09/14/1995). Ex. 5 at 1. They fell out a year later and she had no further ear infections. Ex. 6 at 8.

4
 A vasovagal syncope is a transient vascular and neurologic reaction marked by pallor, nausea, sweating, bradycardia,
and a rapid fall in blood pressure. It can result in loss of consciousness—and did for K.L. Dorland’s Medical
Dictionary 1818 (32nd ed. 2012) (hereinafter “Dorland’s”).



                                                            2
        K.L.’s intake report at Copley sets forth no underlying or concurrent symptoms - she had
no fever, irregular heart rate, or respiratory distress. Ex. 4 at 52-53. She was noted to have an
abrasion and swelling on the right side of her forehead, however, and K.L.’s mom reported that
K.L. had recently had a cold. Id. at 52, 54. In fact, her mother informed initial treaters that prior to
the seizure, K.L. had complained of ear pain, and received Benedryl and Sudafed at home. Ex. 3
at 107. K.L.’s doctor ordered a head and neck CT scan, CBC, and an EKG—all of which were
normal.5 Ex. 4 at 55.

        K.L. was subsequently transported to Fletcher Allen Healthcare at the Vermont Children’s
Hospital (“FAHC”). Ex. 3 at 107. She was intubated and sedated, and treaters performed a lumbar
puncture, MRI6, and EEG. Id. K.L. was also evaluated for a central nervous system infection by
looking at her cerebral spinal fluid (“CSF”) testing from the lumbar puncture, but the results were
negative. Id. She was treated with IV ranitidine for a stress ulcer prophylaxis.7 Id. at 8. Two days
after K.L. was initially sedated, she had her intubation tube removed, and she woke up and was
transferred out of the pediatric intensive care unit. Id. Her doctors at this time proposed that the
cause of her seizure was multi-factoral, “with potential contributors including a mild URI [upper
respiratory infection], OTC pharmacotherapy with Benadryl and Sudafed, and recent HPV vaccine
administration.8” Id. K.L. was discharged on February 13, 2010, and additional test results came
back a few days later. Her MRI was normal, showing no signs of encephalitis, meningitis, or
migrational anomaly or cerebral malformation, and her lumbar puncture was also normal. Id. at
113. Her EEG showed an impaired arousal mechanism, however. Ex. 12 at 16.

        K.L. had a follow-up visit with her primary care physician, Dr. Melissa Volansky, on
February 15, 2010. At that time, she complained of headaches, vomiting, nausea, and dizziness.
Ex. 3 at 16. After examination, Dr. Volansky concluded that K.L.’s recent seizure had an unclear
etiology, speculating that although it “may have been effect of recent Gardasil and/or
decongestants,” it could also simply reflect new onset epilepsy. Id. at 17. She confirmed prior
determinations that there was no sign of infection or brain trauma on imaging; K.L. did have
elevated prolactin9 but pituitary imaging was normal. Id.

           On February 27, 2010, K.L. returned to the FAHC ER after complaints of twitching, arm

5
 CT stands for computed tomography. Dorland’s at 440. CBC is a complete blood count. Id. at 310. EKG is an
electrocardiogram. Id. at 597.
6
    MRI stands for magnetic resonance imaging. Dorland’s at 1184.
7
 Ranitidine inhibits gastric acid and can be used as a prophylactic (a preventive measure) for stress ulcers. Dorland’s
at 1592.
8
    OTC means over the counter medication. Dorland’s at 1350.
9
    Prolactin is a hormone that stimulates and sustains lactation. Dorland’s at 1524.


                                                             3
jerking, and leg buckling. Ex. 3 at 97. While there, K.L. experienced an observed generalized tonic
clonic seizure, which was treated with 1000 mg of Keppra and lorazepam.10 Id. It was noted at this
visit that K.L. had been suffering from a stomach bug for the last few days, but she had experienced
no other seizures or illness since her February 11, 2010 hospitalization. Id. K.L. was discharged
on February 28, 2010 and began a regimen of Keppra 500mg, with the instruction to follow up
with a pediatric neurologist. Id.

         Evaluation of K.L.’s Condition

       K.L. was seen for that follow-up appointment on March 22, 2010, with Dr. Louisa Kalsner.
Dr. Kalsner noted that K.L. had been seizure-free since February 28, 2010, but had been
experiencing some difficulty using her right hand and recalling certain words. Ex. 3 at 150. K.L.
also complained of headaches that she believed may have begun following the receipt of the third
dose of the HPV vaccine. Id. at 149-50. Dr. Kalsner did record that it was notable that K.L.’s first
seizure was two days after she received the third dose of the HPV vaccine. Id. Dr. Kalsner
concluded the visit by prescribing K.L. Ativan, and recommending that she increase her Keppra
dosage to 750 mg. Id.


        In order to gain more insight into the basis and nature of K.L.’s condition, K.L. next saw
Dr. Annapurna Poduri, a neurologist and epileptologist, at Children’s Hospital in Boston,
Massachusetts, on June 1, 2010. Ex. 3 at 143. Dr. Poduri reviewed K.L.’s records and symptoms
progression, taking note of the illness that had occurred around the time of her first seizure, as well
as K.L.’s receipt of the third dose of the HPV vaccine two days prior. Id. at 143. Dr. Poduri’s notes
also record facts suggestive that K.L. might have, in retrospect, experienced some related
symptoms that predated the third HPV dose. Thus, K.L. informed Dr. Poduri that she recalled
experiencing a dead feeling in her arm after throwing a baseball or writing prior to her first seizure,
although she did not state precisely when. Id. at 144. In addition, she noted that a hand-twitching
episode she had experienced in April (as recalled by her mother) may have been similar to prior
experiences at earlier times. Id. (“[s]he admits that she may have had episodes like that in the
past”).

         Dr. Poduri wanted to conduct a more detailed MRI study to make sure K.L. did not have
a small area of abnormality in her brain. Ex. 3 at 146. Moreover, Dr. Poduri stated “given her
[K.L.’s] past history of reading difficulties and the association between periventricular heterotopia
and reading abnormalities and epilepsy typically at this age, I think it would be worth a very careful
look at the periventricular region for small focal heterotopia as well.” Id. at146-47. Based on this
overall examination, Dr. Poduri’s initial conclusion about K.L.’s condition was that she had
experienced a juvenile onset form of idiopathic partial onset epilepsy. Id. at 147. Dr. Poduri

10
   Keppra is the brand name of a prescription medication (levetiracetam) used in the treatment of seizures. Dorland’s
at 978, 1051. Lorazepam is used in the treatment of anxiety as a sedative agent. Id. at 1074

                                                         4
reasoned that this was the most likely diagnosis, given the medical facts, K.L.’s family history,
and her otherwise normal development. Id. She did not attribute K.L.’s seizures to the HPV
vaccine.

        Petitioner was re-evaluated by Dr. Kalsner on June 22, 2010. Ex. 9 at 10. Dr. Kalsner noted
that K.L. had been seizure free for four and one-half months and was doing well on Keppra. Id.
Dr. Kalsner acknowledged that there had previously been “concerns” about the HPV vaccine’s
connection to the first seizure, although she did not (in this record) propose a relationship. Id. Her
notes also stated her awareness that K.L. had been taken to see “an epileptologist in Boston” (Dr.
Poduri), but that the write-up from that visit had not yet been provided to her (and hence her
analysis did not reflect any of Dr. Poduri’s more specialized views). Id. Dr. Kalsner stated that
K.L. was scheduled to receive another MRI shortly thereafter. Id.

        A few days later, on June 30, 2010, K.L. returned to Dr. Poduri, who performed and
reviewed the more detailed MRI. Ex. 3 at 140. She stated that the MRI was “an excellent quality
study that shows a structurally normal brain. No abnormalities were noted.” Id. The MRI results
allowed Dr. Poduri to more conclusively propose, as she had initially speculated, that K.L. had
“partial onset epilepsy that appears to be truly idiopathic.” Id.

        K.L. had no subsequent seizure activity until January 2013, when her treating physicians
attempted to reduce her dosage of Keppra in an effort to wean her off the medication. See Ex. 21
at 4. Because these efforts were unsuccessful, she was again placed on a higher dose of Keppra,
and her seizures remained controlled thereafter. Id. Although K.L. remained seizure-free during
this period, she began to have frequent headaches and vomiting. Ex. 3 at 129. She was diagnosed
with migraines, prescribed medication, and her headaches began to gradually decrease in quantity
and severity. Id. at 116. K.L. was also noted to have functional dyspepsia and gastroparesis, which
was helped by eliminating dairy from her diet.11 Id. at 19. In January 2012, K.L. was seen for
complaints of anxiety and underwent a comprehensive educational evaluation due to difficulty she
was experiencing in college. Id. at 3, see generally Ex. 17. K.L. was diagnosed with a language-
based disorder of written expression, and advised to pursue tutoring along with a reduced course
load. Ex. 7 at 12, 14. To help with her anxiety she was prescribed an anti-depressant and began
seeing a psychiatrist. Ex. 3 at 6.




11
   Functional dyspepsia is the impairment of the power or function of digestion with no physical cause, usually
resulting from nervousness or anxiety. Dorland’s at 579. Gastroparesis is paralysis of the stomach, usually from
damage to its nerve supply, so that food empties out more slowly. Id. at 765.


                                                       5
     II.      EXPERT TESTIMONY

       Both sides offer their own neurologist expert. The opinions and testimony of the relevant
experts are set forth below.

           A. Dr. Beatrice C. Engstrand

        Petitioner’s expert, Beatrice C. Engstrand, M.D., provided an opinion for the theoretical
causative role the HPV vaccine could play in seizures and other neurological conditions. She filed
three expert reports in this case, and also testified at the hearing. See Ex. 23, filed on June 20, 2014
(“First Engstrand Rep.”); Ex. 28, filed on December 12, 2014 (“Second Engstrand Rep.”); Ex. 31,
filed May 18, 2015 (“Third Engstrand Rep.”); Transcript (“Tr.”) at 6-42. In addition, after the
hearing Dr. Engstrand filed an affidavit offering additional medical literature along with an
explanation of their significance. See Ex. 40, filed on November 4, 2016 (“Engstrand Aff.”).

        Dr. Engstrand graduated from the Medical College of Pennsylvania in 1984 (after obtaining
her bachelor’s degree at Lehigh University). Ex. 24 at 4 (Dr. Engstrand’s CV). She completed
three residencies - one in medicine at the North Shore University Hospital, and two in neurology
at The New York Hospital/Cornell Medical Center and SUNY Health Science Center. Id. at 3-4.
Dr. Engstrand is board certified in neurology. Id. at 1. She currently works in private practice and
is a Clinical Associate Professor of Neurology at the New York Medical College. Id. Her practice
involves the treatment and evaluation of adolescents and adults who suffer from various forms of
acute and chronic neurological conditions—20 percent of whom suffer from seizures. First
Engstrand Rep. at 2, Tr. at 10. As she acknowledged at hearing, however, Dr. Engstrand lacks
specialized expertise in the condition of epilepsy (whether in her education, or through research or
study), other than from what she has learned from those patients she has seen with it. Tr. at 10.12

        Dr. Engstrand opined that the HPV vaccine caused K.L.’s “persistent neurological
sequelae, poor concentration, migraines, learning disorder, and seizure disorder.” First Engstrand
Rep. at 4. She initially proposed that the most likely mechanism for causation was “the release of
the cytokine interleukin 1 beta in the course of the immune response to a[n] infectious agent such
as a vaccine, [that] could in turn trigger a cluster of afebrile convulsions or seizures.” Id.
Specifically, she posited that this process created agitation in K.L.’s brain leading to right arm
shaking and her generalized seizure. Tr. at 8.

         In so opining, Dr. Engstrand relied on the fact that, as noted above, certain treater records
initially included the third HPV vaccine dose in the differential diagnosis as a possible causative

12
   I also note that Dr. Engstrand is not an immunologist – although neither is Dr. Shinnar, for that matter. However,
this lack of specific expertise on a matter relevant to the resolution of the case cuts more against Petitioner than
Respondent, since Petitioner bears the initial, and ultimate, burden of proof. Moberly v. Sec’y of Health & Human
Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010).

                                                         6
factor. First Engstrand Rep. at 3. She also referenced a piece of literature involving observed
adverse incidents from nearly 700,000 HPV vaccine doses given to females between the ages of
13 and 15 in Ontario, Canada from September 2007 to December 2011. T. Harris, et al., Adverse
Events Following Immunization in Ontario’s Female School-Based HPV Program, 32 Vaccine
1061, 1061-66 (2014), filed as Ex. 25 (“Harris”). Harris, however, specified only two instances of
seizure following the HPV vaccine – and one involved an individual with a prior pediatric history
of febrile seizures, as well as a pre-vaccination epilepsy diagnosis. Harris at 1063. Dr. Engstrand
offered an additional article discussing autoimmune reactions to the HPV vaccine, although the
article makes no reference to an autoimmune form of epilepsy (or any form, for that matter). P.
Pellegrino, et al., On the Relationship Between Human Papillomavirus Vaccine and Autoimmune
Diseases, 13 Autoimmunity Revs., 736, 736-41 (2014), filed as Ex. 27.

        Dr. Engstrand’s second report was aimed at addressing the informational categories
identified in Special Master Moran’s Order13 pertaining to the use of expert reports as direct
testimony, and therefore mostly responded to questions that the Order had indicated needed
answers. See generally Second Engstrand Rep. Dr. Engstrand did, however, attempt to bulwark or
add details to aspects of her opinion as expressed in her first report. Thus, she now emphasized
that K.L. had displayed no seizure-like or other medical symptoms before her initial seizure on
February 11, 2010. Second Engstrand Rep. at 1.

        Dr. Engstrand also offered an additional article from a Spanish medical journal – M.A.
Rodriguez-Galán, et al., Adverse Reactions to the Human Papillomavirus Vaccine in the Valencian
Community (2007-2011), 81 Anales Pediatria 303, 303-309 (2014), filed as Ex. 29 (the “Valencian
Article”). The Valencian article was a retrospective study of reported adverse events (via a Spanish
passive reporting system similar to the VAERS system14 utilized in the United States) in a region
of Spain after administration of 187,385 doses of the HPV vaccine to young females between
September 2007 and December 2011. Valencian Article at 305. Out of 194 adverse reporting
incidents reviewed, only six reported seizures – four of which were connected to syncope. Id. at
306-07.

       In the spring of 2015, Dr. Engstrand filed her third report, which mainly sought to rebut
points made by Respondent’s expert, Dr. Shlomo Shinnar, in his report. Thus, she maintained that
autoimmune-related epilepsy was more common than Dr. Shinnar allowed, and that it could
manifest without evidence on an EEG and without a prior or concurrent fever. Third Engstrand

13
   As will be discussed in the procedural history section below, Special Master Moran presided over this case before
it was transferred to me on April 2, 2014, and had previously ordered the parties to address specific topics in their
written reports, so that those reports could be treated as direct testimony at hearing.
14
  VAERS is the Vaccine Adverse Event Reporting System, which allows doctors and patients to self-report any
potential reactions to vaccines into a database. Centers for Disease Control and Prevention, Vaccine Adverse Event
Reporting System (VAERS), Vaccine Safety (last updated Aug. 28, 2015).


                                                         7
Rep. at 1. Indeed, she made the general assertion that some of K.L.’s observed symptoms, like
migraines, could be associated with epilepsy, while denying the importance of the absence of other
corroborative evidence usually associated with autoimmune diseases (for example, CSF testing
revealing the presence of inflammation), which in her view did not conclusively rule out the
existence of an autoimmune reaction. Id. at 2. She also offered additional literature which either
provided further information about the risks of the HPV vaccine15or generally discussed the nature
of epilepsy. Id. at 3-4.

        At hearing, Dr. Engstrand refined components of her opinion as set forth in her expert
reports. For instance, and in response to Dr. Shinnar’s assertion that the IL-1 beta cytokine was
predominantly associated with fever16 – something K.L. had unquestionably not experienced at
the time of her initial seizure – Dr. Engstrand stated that she no longer relied exclusively on IL-1
beta as the most likely mechanism of injury. Tr. at 19. Rather, she more generally stated that some
“signaling cytokine would be the mechanism based on an immune response that she had to have
seen.” Id. In connection with this assertion, she further maintained that scientific literature existed
that connected the HPV vaccine to afebrile seizures (although such literature had not been filed by
Petitioner at the time of hearing). Dr. Engstrand also asserted that the Valencian Article provided
additional evidence of instances of afebrile seizures following the HPV vaccine. Id. at 23-25. She
admitted that in fact the reported instances of post-vaccination seizures in that article were silent
on whether the individuals at issue had fevers at the time, but maintained that the Valencian Article
would have reported this if so (and therefore it could be assumed from the omission of that fact
that the seizures were afebrile). Id. at 26.

        Dr. Engstrand admitted that she could not point to any testing results from K.L.’s initial
hospitalization that confirmed K.L. had experienced an autoimmune reaction to the HPV vaccine.
Tr. at 33-35. But she discounted the absence of such evidence (see, e.g., Tr. at 35 (“[l]ike
sometimes you could have inflammation show up on an MRI, but you don’t always need it to show
up”)), or attributed the lack of corroborative proof to a failure to test for the proper autoimmune
markers. Id. at 34. She did deem significant the evidence about changes in K.L.’s mental status
post-vaccination (Tr. at 14-17), but agreed that to her the most telling proof that the HPV vaccine
had caused K.L.’s seizure was the close temporal relationship between the two. Id. at 14 (“[s]he
had never had a seizure prior to the vaccine and it was within the time frame two days later . . .”).

         As noted above, after the hearing Petitioner filed an affidavit from Dr. Engstrand


 For example, Dr. Engstrand offered L. Tomlijenovic, et al., Too Fast or Not Too Fast: The FDA’s Approval of
15

Merck’s HPV Vaccine Gardasil, Conflicts Int. Prac. Med., 673, 673-81 (2012), an article exploring the risks of the
HPV vaccine compared to its benefits.
16
  Dr. Shinnar’s report had cited to literature that presented the well-accepted concept that IL-1 beta can trigger a
febrile seizure. Gatti S, et al., Febrile Seizures (Tallie Z. Baram, Shlomo Shinnar eds., Academic Press 2002) at 169-
88, filed as Ex. M (“Gatti”), see also Ex. A at 7.


                                                          8
explaining the relevance of four additional items offered post-hearing in support of Petitioner’s
claim.17 In particular, Dr. Engstrand offered an article that she represented further supported the
possibility of afebrile seizures following the HPV vaccine. See N. Crawford, et al., Syncope and
Seizures Following Human Papillomavirus Vaccination: A Retrospective Case Series, 194 Med.
J. Austl., 16-18 (2011) filed as Ex. 41 (“Crawford”). Crawford, like the Valencian Article, involved
a retrospective study of passive surveillance reporting of alleged vaccine adverse events, here
based on the HPV vaccine’s administration in Australia to young females. Crawford at 16. The
majority of observed events involved a combination of syncope with seizure, with only three study
subjects experiencing afebrile seizure without syncope – although all three instances involved
individuals with a “confirmed underlying epilepsy disorder.” Id.

        Dr. Engstrand also offered an additional article to bulwark her opinion on the role cytokine
production allegedly played herein. See G. Li, et al., Cytokines and Epilepsy, 20 Seizure 249, 249-
56 (2011), filed as Ex. 42 (“Li”). The authors of Li reviewed studies involving cytokines’s role in
epilepsy. Li concluded that an array of different cytokines were involved – but more importantly
(for present purposes), that the cytokines were activated only after the patient had suffered a
seizure, as opposed to causing them, and it could not be fully ascertained in any event whether
post-seizure cytokines exacerbated seizure activity. Li at 256 (“[cytokines] are activated by
seizures, but their precise role in epilepsy is not yet clear”). And Dr. Engstrand filed S. von
Spiczak, et al., A retrospective population-based study on seizures related to Childhood
Vaccination, 52 Epilepsia, 1506, 1506-12 (2011) filed as Ex. 43 (“Spiczak”), which surveyed the
German database of adverse events following vaccination (presumably similar to the VAERS
database) for reported seizures in children up to the age of six. The study found that 17.8 percent
of the children who experienced afebrile seizures had them within 7.5 days of vaccination -
although none had been immunized by the HPV vaccine. Id.


         B.       Dr. Shlomo Shinnar

        Dr. Shinnar filed a single report in this case on behalf of Respondent, along with 20 pieces
of medical literature. See generally Report, dated August 25, 2014, filed as Respondent’s Exhibit
A (ECF No. 56) (“Shinnar Rep.”). He contested Dr. Engstrand’s theory in its entirety, maintaining
that there is no evidence persuasively linking the HPV vaccine to epilepsy, that K.L. had not
experienced an autoimmune reaction, and that the most likely proper diagnosis for her was

17
  Dr. Engstrand’s affidavit attributes the late filing of these items to personal problems she was dealing with relating
to a family member’s sick care. Engstrand Aff. at 1. Putting aside the fact that sixteen months had passed from the
date of her last report, however, none of the articles were recently-published – indeed, all four were published in 2011,
before this case was even filed. Although I permitted these items into the record and have considered them in reaching
my decision, Petitioner has offered no persuasive explanation for their dilatory filing, and it is reasonable to assume
that the items in question were not deemed sufficiently important by Petitioner or Dr. Engstrand to have included in
any of her first three reports filed prior to hearing.


                                                           9
idiopathic epilepsy. Id.

         Dr. Shinnar completed his medical degree at the Albert Einstein College of Medicine in
the Bronx, New York (after completing his undergraduate degree from Columbia College). Ex. B
(Dr. Shinnar’s CV). He went to Johns Hopkins Hospital in Baltimore, Maryland and served as an
assistant Resident and Fellow in Pediatrics followed by a Residency and Fellowship in Neurology.
Id. at 1. Dr. Shinnar is board certified in Neurology with special competence in Child Neurology
and added qualifications in Clinical Neurophysiology and Epilepsy. Shinnar Rep. at 1. He
currently works as a Professor of Neurology, Pediatrics and Epidemiology, and Population Health
at Albert Einstein College of Medicine. Id. Dr. Shinnar serves as the Hyman Climenko Professor
of Neuroscience Research and the Director of the Comprehensive Epilepsy Management Center
at Montefiore Medical Center and the Albert Einstein College of Medicine. Id. Moreover, as the
Director of the Comprehensive Epilepsy Management Center, he has treated and supervised the
treatment of thousands of children suffering from seizure disorders. Id. Dr. Shinnar has also been
awarded grants by the National Institutes of Health to research childhood afebrile seizures as well
as childhood onset epilepsy. Id.

        Dr. Shinnar’s report provides a detailed review of K.L.’s medical history relevant to her
illness herein. Shinnar Rep. at 2-5. Based upon that review, Dr. Shinnar concluded (consistent with
treaters like Dr. Poduri) that K.L. suffers from idiopathic epilepsy. Id. at 6. Dr. Shinnar agreed that
K.L. had epilepsy based on her clinical presentation of two or more unprovoked seizures more
than 24 hours apart. Id. at 7-8. Dr. Shinnar noted that he was particularly persuaded by the reports
written by Dr. Poduri, as she is a “renowned epilepsy expert,” making her opinions about the
etiology of K.L.’s epilepsy more trustworthy than K.L.’s other treaters (who were more general
neurologists). Tr. at 67.18

        Dr. Shinnar contrasted K.L.’s condition, as revealed in the medical records, with
autoimmune epilepsy. In his explanation, autoimmune epilepsy is a rare condition characterized
by intractable seizures19 and a markedly abnormal and encephalopathic EEG, along with
epileptiform activity20, all of which he contended were not present in K.L. Id.; see also Tr. 65, 72-
74. K.L.’s normal EEG, MRI, and lumbar puncture all failed to support the conclusion that K.L.
had experienced an immune-mediated encephalopathy, given the absence of evidence of

18
   As a possible explanation for K.L.’s epilepsy, Dr. Shinnar proposed at hearing that her family history might suggest
an underlying susceptibility, or the preexisting viral syndrome she was reported to be suffering from at the time of her
first hospitalization. Tr. at 44. He did not, however, elaborate at length upon either of these possible alternative
explanations.
19
     Intractable seizures are those that are resistant to cure, relief or control. Dorland’s at 953.
20
  J. Suleiman, et al., Autoimmune Epilepsy in Children: Case Series and Proposed Guidelines for Identification, 54
Epilepsia 1036, 1039 fig. 1 (2013) filed as Ex. L.


                                                               10
inflammation and other autoimmune red flags. Id. at 8.

         Beyond outlining the nature of K.L.’s condition, Dr. Shinnar opined that the HPV vaccine
could not affirmatively be linked to epilepsy. In support, he cited a large population study of young
girls in Denmark and Sweden. See L. Arnheim-Dahlstrom et al., Autoimmune, Neurological and
Venous Thromboembolic Adverse Events after Immunization of Adolescent Girls with
Quadrivalent Human Papillomavirus Vaccine in Denmark and Sweden: Cohort Study, BMJ (Aug.
28, 2013), http://www.bmj.com/content/347/bmj.f5906?tab=related#webextra filed as Ex. S
(“Arnheim-Dahlstrom”). That study found no increased risk for autoimmune or neurological
events among the nearly 300,000 patients who received multiple doses of the HPV vaccine. Id. at
1. In contrast, Dr. Shinnar noted, the study found that the seizure rate was higher in the girls that
did not receive the HPV vaccine. Tr. at 53.

        Dr. Shinnar took particular issue with Dr. Engstrand’s theory that the cytokine IL-1 beta
was the mechanism for injury. As he noted, there is strong scientific support for the concept that
IL-1 beta is the chief cytokine that mediates fever and has been associated with febrile seizures,
but not afebrile seizures like K.L. experienced. Shinnar Rep. at 8; see also Tr. at 43 (“you cannot
have an IL-1 beta mediated reaction that does not involve a fever”); Gatti at 171.

        Dr. Shinnar also noted that K.L.’s seizure after being weaned of her medication was
consistent with the conclusion that she suffered only from adolescent onset epilepsy, which is often
easier to control but can relapse when the patient’s dosage is reduced. Shinnar Rep. at 8. Petitioner
attacked this assertion at hearing, in an attempt to suggest that because K.L. was still on her
medication at the time of that seizure, the medication was not effective against her condition, and
thus it was less likely that K.L.’s epilepsy was idiopathic. Tr. at 48. But Dr. Shinnar maintained
his position, rejecting the argument that weaning K.L. off Keppra was the same as treating her
with the full dose. Tr. 48, 52. In his view, K.L.’s seizures were fully controlled on her full dose;
when that dose was reduced, it naturally caused her to have a seizure, but once she was back on
her full dose she remained seizure-free, and therefore the results of weaning did not undermine his
conclusions. Id.

        Dr. Shinnar ended his testimony by rejecting the Valencian Article offered by Dr.
Engstrand as unreliable support for Petitioner’s theory. After attacking the overall prestige of the
medical journal in which the item was published, Dr. Shinnar observed that the Valencian Article
relied on self-reported adverse events (which could be incorrect), in comparison to more
trustworthy retrospective epidemiologic studies like Arnheim-Dahlstrom, which examined actual
diagnosed reactions after vaccination. Tr. at 68. He also pointed to the range for the rate of seizures
observed in the Valencian Article, which was from minus .3 to 1.1; because statistics are bound
by zero (since there cannot be a rate of seizures lower than 0) the range cast doubt on the overall
validity of the researchers’ calculations. Id. at 69.


                                                  11
III.     PROCEDURAL BACKGROUND

        After initiating this action in May 2012, K.L. began filing medical records in support of
her claim, completing the process approximately one year later. Respondent’s Rule 4(c) Report
was then filed in June of 2013. ECF No. 30. Petitioner was ordered to file an expert report by
March 31, 2014 but subsequently requested numerous extensions of time to do so, accomplishing
the task by mid-June of 2014 (and thereby allowing another year to pass). ECF No. 54. In the
meantime, the matter (originally before Special Master Moran) had been assigned to me on April
2, 2014.

        Over the next year, both parties filed additional expert reports and medical literature as
noted above, and on October 13, 2015 the matter was set for hearing on September 27, 2016 in
Washington, D.C. See Prehearing Order, dated October 13, 2015 (ECF No. 88). Importantly, the
matter remained subject to an earlier order entered by Special Master Moran providing (in an effort
to expedite the case’s adjudication if heard at trial) that each side’s expert’s reports would be
considered their direct testimony, thereby allowing their testimony to begin with cross-
examination.21 See Scheduling Order dated Jan. 15, 2014 (ECF No. 42).

        The hearing went forward as scheduled, and the parties elected to file simultaneous post-
hearing briefs, and they did so on November 14, 2016. See ECF No. 114,115. This matter is now
ripe for a decision.

IV.      APPLICABLE LAW

         A. Petitioner’s Overall Burden in Vaccine Program Cases

        To receive compensation in the Vaccine Program, a petitioner must prove either: (1) that
he suffered a “Table Injury” – i.e., an injury falling within the Vaccine Injury Table –
corresponding to one of the vaccinations in question within a statutorily prescribed period of time
or, in the alternative, (2) that his illnesses were actually caused by a vaccine (a “Non-Table
Injury”). See Sections 13(a)(1)(A), 11(c)(1), and 14(a), as amended by 42 C.F.R. § 100.3; §
11(c)(1)(C)(ii)(I); see also Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1321 (Fed.
Cir. 2010); Capizzano v. Sec’y of Health & Human Servs., 440 F.3d 1317, 1320 (Fed. Cir. 2006).22


21
   Application of this order did not appreciably hinder my ability to understand Petitioner’s theory of the case, nor
would have hearing the full direct testimony aided my ruling on this matter. To the contrary - it was helpful in
streamlining the parties’ argument, to the extent it directed the parties to address certain topics highly relevant to the
case’s resolution. It also assisted in reducing overall trial time.
22
  Decisions of special masters (some of which I reference in this ruling) constitute persuasive but not binding
authority. Hanlon v. Sec’y of Health & Human Servs., 40 Fed. Cl. 625, 630 (1998). By contrast, Federal Circuit rulings
concerning legal issues are binding on special masters. Guillory v. Sec’y of Health & Human Servs., 59 Fed. Cl. 121,

                                                           12
In this case, Petitioner does not assert a Table claim.

         For both Table and Non-Table claims, Vaccine Program petitioners bear a “preponderance
of the evidence” burden of proof. Section 13(1)(a). That is, a petitioner must offer evidence that
leads the “trier of fact to believe that the existence of a fact is more probable than its nonexistence
before [he] may find in favor of the party who has the burden to persuade the judge of the fact’s
existence.” Moberly, 592 F.3d at 1322 n.2; see also Snowbank Enter. v. United States, 6 Cl. Ct.
476, 486 (1984) (mere conjecture or speculation is insufficient under a preponderance standard).
Proof of medical certainty is not required. Bunting v. Sec’y of Health & Human Servs., 931 F.2d
867, 873 (Fed. Cir. 1991). In particular, a petitioner must demonstrate that the vaccine was “not
only [the] but-for cause of the injury but also a substantial factor in bringing about the injury.”
Moberly, 592 F.3d at 1321 (quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344,
1352-53 (Fed. Cir. 1999)); Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352, 1355 (Fed.
Cir. 2006). A petitioner may not receive a Vaccine Program award based solely on his assertions;
rather, the petition must be supported by either medical records or by the opinion of a competent
physician. Section 13(a)(1).

        In attempting to establish entitlement to a Vaccine Program award of compensation for a
Non-Table claim, a petitioner must satisfy all three of the elements established by the Federal
Circuit in Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005) : “(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
proximate temporal relationship between vaccination and injury.” Althen, 418 F.3d at 1278.

        Each of the Althen prongs requires a different showing. Under Althen prong one, petitioners
must provide a “reputable medical theory,” demonstrating that the vaccine received can cause the
type of injury alleged. Pafford, 451 F.3d at 1355-56 (citations omitted). To satisfy this prong, a
petitioner’s theory must be based on a “sound and reliable medical or scientific explanation.”
Knudsen v. Sec’y of Health & Human Servs., 35 F.3d 543, 548 (Fed. Cir. 1994). Such a theory
must only be “legally probable, not medically or scientifically certain.” Id. at 549.

        Petitioners may satisfy the first Althen prong without resort to medical literature,
epidemiological studies, demonstration of a specific mechanism, or a generally accepted medical
theory. Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1378-79 (Fed. Cir. 2009) (citing
Capizzano, 440 F.3d at 1325-26). Special masters, despite their expertise, are not empowered by
statute to conclusively resolve what are essentially thorny scientific and medical questions, and
thus scientific evidence offered to establish Althen prong one is viewed “not through the lens of
the laboratorian, but instead from the vantage point of the Vaccine Act’s preponderant evidence

124 (2003), aff’d 104 F. App’x 712 (Fed. Cir. 2004); see also Spooner v. Sec’y of Health & Human Servs., No. 13-
159V, 2014 WL 504728, at *7 n.12 (Fed. Cl. Spec. Mstr. Jan. 16, 2014).

                                                      13
standard.” Id. at 1380. Accordingly, special masters must take care not to increase the burden
placed on petitioners in offering a scientific theory linking vaccine to injury. Contreras v. Sec’y of
Health & Human Servs., 121 Fed. Cl. 230, 245 (2015) (“[p]lausibility . . . in many cases may be
enough to satisfy Althen prong one” (emphasis in original)), vacated on other grounds, No. 2015-
5097 (Fed. Cir. Jan. 3, 2017). But this does not negate or reduce a petitioner’s ultimate burden to
establish his overall entitlement to damages by preponderant evidence. W.C. v. Sec’y of Health &
Human Servs., 704 F.3d 1352, 1356 (Fed. Cir. 2013) (citations omitted).23

        The second Althen prong requires proof of a logical sequence of cause and effect, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at 1278; Andreu,
569 F.3d at 1375-77; Capizzano, 440 F.3d at 1326; Grant v. Sec’y of Health & Human Servs., 956
F.2d 1144, 1148 (Fed. Cir. 1992). In establishing that a vaccine “did cause” injury, the opinions
and views of the injured party’s treating physicians are entitled to some weight. Andreu, 569 F.3d
at 1367; Capizzano, 440 F.3d at 1326 (“medical records and medical opinion testimony are favored
in vaccine cases, as treating physicians are likely to be in the best position to determine whether a
‘logical sequence of cause and effect show[s] that the vaccination was the reason for the injury’”)
(quoting Althen, 418 F.3d at 1280). Medical records are generally viewed as particularly
trustworthy evidence, since they are created contemporaneously with the treatment of the patient.
Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).

        However, medical records and/or statements of a treating physician’s views do not per se
bind the special master to adopt the conclusions of such an individual, even if they must be
considered and carefully evaluated. Section 13(b)(1) (providing that “[a]ny such diagnosis,
conclusion, judgment, test result, report, or summary shall not be binding on the special master or
court”); Snyder v. Sec’y of Health & Human Servs., 88 Fed. Cl. 706, 746 n.67 (2009) (“there is
nothing . . . that mandates that the testimony of a treating physician is sacrosanct – that it must be
accepted in its entirety and cannot be rebutted”). As with expert testimony offered to establish a
theory of causation, the opinions or diagnoses of treating physicians are only as trustworthy as the
reasonableness of their suppositions or bases. The views of treating physicians should also be
weighed against other, contrary evidence also present in the record – including conflicting opinions
among such individuals. Hibbard v. Sec’y of Health & Human Servs., 100 Fed. Cl. 742, 749 (2011)
(not arbitrary or capricious for special master to weigh competing treating physicians’ conclusions
against each other), aff’d, 698 F.3d 1355 (Fed. Cir. 2012); Caves v. Sec’y of Dept. of Health &
Human Servs., No. 06-522V, 2011 WL 1935813, at *17 (Fed. Cl. Spec. Mstr. Apr. 29, 2011), mot.
for review den’d, 100 Fed. Cl. 344, 356 (2011), aff’d without opinion, 475 Fed. App’x 765 (Fed.
Cir. 2012).

23
  Although decisions like Contreras suggest that the burden of proof required to satisfy the first Althen prong is less
than the other two, there is ample contrary authority for the more straightforward proposition that the first Althen
prong, like the overall test itself, simply applies a preponderance standard when evaluating if a reliable and plausible
causal theory has been established. Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339, 1350 (Fed. Cir.
2010).

                                                          14
        The third Althen prong requires establishing a “proximate temporal relationship” between
the vaccination and the injury alleged. Althen, 418 F.3d at 1281. That term has been equated to the
phrase “medically-acceptable temporal relationship.” Id. A petitioner must offer “preponderant
proof that the onset of symptoms occurred within a timeframe which, given the medical
understanding of the disorder’s etiology, it is medically acceptable to infer causation.” de Bazan
v. Sec’y of Health & Human Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008). The explanation for
what is a medically acceptable timeframe must also coincide with the theory of how the relevant
vaccine can cause an injury (Althen prong one’s requirement). Id. at 1352; Shapiro v. Sec’y of
Health & Human Servs., 101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl.
353 (2012), aff’d mem., 2013 WL 1896173 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Human
Servs., No. 11-355V, 2013 WL 3214877 (Fed. Cl. Spec. Mstr. May 30, 2013), mot. for review
den’d (Fed. Cl. Dec. 3, 2013), aff’d, 773 F.3d 1239 (Fed. Cir. 2014).

       B. Law Governing Analysis of Fact Evidence

        The process for making determinations in Vaccine Program cases regarding factual issues
begins with consideration of the medical records. Section 11(c)(2). The special master is required
to consider “all [] relevant medical and scientific evidence contained in the record,” including “any
diagnosis, conclusion, medical judgment, or autopsy or coroner’s report which is contained in the
record regarding the nature, causation, and aggravation of the petitioner’s illness, disability, injury,
condition, or death,” as well as the “results of any diagnostic or evaluative test which are contained
in the record and the summaries and conclusions.” Section 13(b)(1)(A). The special master is then
required to weigh the evidence presented, including contemporaneous medical records and
testimony. See Burns v. Sec’y of Health & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (it is
within the special master’s discretion to determine whether to afford greater weight to
contemporaneous medical records than to other evidence, such as oral testimony surrounding the
events in question that was given at a later date, provided that such determination is evidenced by
a rational determination).

        Medical records that are created contemporaneously with the events they describe are
presumed to be accurate and “complete” (i.e., presenting all relevant information on a patient’s
health problems). Cucuras, 993 F.2d at 1528; Doe/70 v. Sec’y of Health & Human Servs., 95 Fed.
Cl. 598, 608 (2010) (“[g]iven the inconsistencies between petitioner’s testimony and his
contemporaneous medical records, the special master’s decision to rely on petitioner’s medical
records was rational and consistent with applicable law”), aff’d, Rickett v. Sec’y of Health &
Human Servs., 468 F. App’x 952 (Fed. Cir. 2011) (non-precedential opinion). This presumption is
based on the linked propositions that (i) sick people visit medical professionals; (ii) sick people
honestly report their health problems to those professionals; and (iii) medical professionals record
what they are told or observe when examining their patients in as accurate a manner as possible,


                                                  15
so that they are aware of enough relevant facts to make appropriate treatment decisions. Sanchez
v. Sec’y of Health & Human Servs., No. 11-685V, 2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr.
Apr. 10, 2013); Cucuras v. Sec’y of Health & Human Servs., 26 Cl. Ct. 537, 543 (1992), aff’d, 993
F.2d at 1525 (Fed. Cir. 1993) (“[i]t strains reason to conclude that petitioners would fail to
accurately report the onset of their daughter’s symptoms.”).

        Accordingly, if the medical records are clear, consistent, and complete, then they should
be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-1585V, 2005
WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). Indeed, contemporaneous medical
records are generally found to be deserving of greater evidentiary weight than oral testimony –
especially where such testimony conflicts with the record evidence. Cucuras, 993 F.2d at 1528;
see also Murphy v. Sec’y of Health & Human Servs., 23 Cl. Ct. 726, 733 (1991), aff’d per curiam,
968 F.2d 1226 (Fed. Cir. 1992), cert. den’d, Murphy v. Sullivan, 506 U.S. 974 (1992) (citing United
States v. United States Gypsum Co., 333 U.S. 364, 396 (1947) (“[i]t has generally been held that
oral testimony which is in conflict with contemporaneous documents is entitled to little evidentiary
weight.”)).

        However, there are situations in which compelling oral testimony may be more persuasive
than written records, such as where records are deemed to be incomplete or inaccurate. Campbell
v. Sec’y of Health & Human Servs., 69 Fed. Cl. 775, 779 (2006) (“like any norm based upon
common sense and experience, this rule should not be treated as an absolute and must yield where
the factual predicates for its application are weak or lacking”); Lowrie, 2005 WL 6117475, at *19
(“[w]ritten records which are, themselves, inconsistent, should be accorded less deference than
those which are internally consistent”) (quoting Murphy, 23 Cl. Ct. at 733)). Ultimately, a
determination regarding a witness’s credibility is needed when determining the weight that such
testimony should be afforded. Andreu, 569 F.3d at 1379; Bradley v. Sec’y of Health & Human
Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).

        When witness testimony is offered to overcome the presumption of accuracy afforded to
contemporaneous medical records, such testimony must be “consistent, clear, cogent, and
compelling.” Sanchez, 2013 WL 1880825, at *3 (citing Blutstein v. Sec’y of Health & Human
Servs., No. 90-2808V, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). In
determining the accuracy and completeness of medical records, the Court of Federal Claims has
listed four possible explanations for inconsistencies between contemporaneously created medical
records and later testimony: (1) a person’s failure to recount to the medical professional everything
that happened during the relevant time period; (2) the medical professional’s failure to document
everything reported to her or him; (3) a person’s faulty recollection of the events when presenting
testimony; or (4) a person’s purposeful recounting of symptoms that did not exist. La Londe v.
Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013), aff’d, 746 F.3d 1334 (Fed. Cir.
2014). In making a determination regarding whether to afford greater weight to contemporaneous


                                                 16
medical records or other evidence, such as testimony at hearing, there must be evidence that this
decision was the result of a rational determination. Burns, 3 F.3d at 417.

       C. Analysis of Expert Testimony

        Establishing a sound and reliable medical theory often requires a petitioner to present
expert testimony in support of his claim. Lampe v. Sec’y of Health & Human Servs., 219 F.3d
1357, 1361 (Fed. Cir. 2000). Vaccine Program expert testimony is usually evaluated according to
the factors for analyzing scientific reliability set forth in Daubert v. Merrell Dow Pharm., Inc., 509
U.S. 579, 594-96 (1993). See Cedillo v. Sec’y of Health & Human Servs., 617 F.3d 1328, 1339
(Fed. Cir. 2010) (citing Terran v. Sec’y of Health & Human Servs., 195 F.3d 1302, 1316 (Fed. Cir.
1999). “The Daubert factors for analyzing the reliability of testimony are: (1) whether a theory or
technique can be (and has been) tested; (2) whether the theory or technique has been subjected to
peer review and publication; (3) whether there is a known or potential rate of error and whether
there are standards for controlling the error; and (4) whether the theory or technique enjoys general
acceptance within a relevant scientific community.” Terran, 195 F.3d at 1316 n.2 (citing Daubert,
509 U.S. at 592-95).

         The Daubert factors play a slightly different role in Vaccine Program cases than they do
when applied in other federal judicial for a (such as the district courts). Daubert factors are usually
employed by judges (in the performance of their evidentiary gatekeeper roles) to exclude evidence
that is unreliable and/or could confuse a jury. In Vaccine Program cases, by contrast, these factors
are used in the weighing of the reliability of scientific evidence proffered. Davis v. Sec’y of Health
& Human Servs., 94 Fed. Cl. 53, 66-67 (2010) (“uniquely in this Circuit, the Daubert factors have
been employed also as an acceptable evidentiary-gauging tool with respect to persuasiveness of
expert testimony already admitted”). The flexible use of the Daubert factors to evaluate the
persuasiveness and reliability of expert testimony has routinely been upheld. See, e.g., Snyder, 88
Fed. Cl. at 742-45. In this matter (as in numerous other Vaccine Program cases), Daubert has not
been employed at the threshold, to determine what evidence should be admitted, but instead to
determine whether expert testimony offered is reliable and/or persuasive.

        Respondent frequently offers one or more experts of her own in order to rebut a petitioner’s
case. Where both sides offer expert testimony, a special master’s decision may be “based on the
credibility of the experts and the relative persuasiveness of their competing theories.”
Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339, 1347 (Fed. Cir. 2010) (citing
Lampe, 219 F.3d at 1362). However, nothing requires the acceptance of an expert’s conclusion
“connected to existing data only by the ipse dixit of the expert,” especially if “there is simply too
great an analytical gap between the data and the opinion proffered.” Snyder, 88 Fed. Cl. at 743
(quoting Gen. Elec. Co. v. Joiner, 522 U.S. 146 91997)); see also Isaac v. Sec’y of Health &
Human Servs., No. 08-601V, 2012 WL 3609993, at *17 (Fed. Cl. Spec. Mstr. July 30, 2012), mot.


                                                  17
for review den’d, 108 Fed. Cl. 743 (2013), aff’d, 540 Fed. App’x 999 (Fed. Cir. 2013) (citing
Cedillo, 617 F.3d at 1339). Weighing the relative persuasiveness of competing expert testimony,
based on a particular expert’s credibility, is part of the overall reliability analysis to which special
masters must subject expert testimony in Vaccine Program cases. Moberly, 592 F.3d at 1325-26
(“[a]ssessments as to the reliability of expert testimony often turn on credibility determinations”);
see also Porter v. Sec’y of Health & Human Servs., 663 F.3d 1242, 1250 (Fed. Cir. 2011) (“this
court has unambiguously explained that special masters are expected to consider the credibility of
expert witnesses in evaluating petitions for compensation under the Vaccine Act”).

       D. Consideration of Medical Literature

        Both parties filed medical and scientific literature in this case, but not all factor into the
outcome of this decision. While I have reviewed all of the medical literature submitted in this case,
I discuss only those articles that are most relevant to my determination and/or are central to
Petitioner’s case – just as I have not exhaustively discussed every individual medical record filed.
Moriarty v. Sec’y of Health & Human Servs., No. 2015-5072, 2016 WL 1358616, at *5 (Fed. Cir.
Apr. 6, 2016) (“[w]e generally presume that a special master considered the relevant record
evidence even though he does not explicitly reference such evidence in his decision”) (citation
omitted); see also Paterek v. v. Sec’y of Health & Human Servs., 527 F. App'x 875, 884 (Fed. Cir.
2013) (“[f]inding certain information not relevant does not lead to – and likely undermines – the
conclusion that it was not considered”).

                                             ANALYSIS


        Petitioner has not carried her burden of proof in this case. Beyond the close temporal
relationship between K.L.’s receipt of the third dose of Gardasil and onset of her first diagnosed
seizure, the medical record does not support the conclusion that her epilepsy was vaccine-caused.
More fundamentally, she has not established a reliable scientific theory that the HPV vaccine could
cause epilepsy of the kind experienced by Petitioner.


   A. Althen Prong One


        Through Dr. Engstrand’s testimony, Petitioner proposes that an autoimmune response can
occur when the HPV vaccine encourages the production of various cytokines in the body, which
can in turn cause inflammatory signaling to the brain, making it hyper-excitable and resulting in a
generalized seizure. Tr. 6-7. This causation theory has a number of self-evident deficiencies.

        An overarching problem with Petitioner’s theory is the extent to which it exceeds the
expertise of Dr. Engstrand to espouse. As a general neurologist who sees patients with seizures

                                                  18
(about 20 percent of her patients), Dr. Engstrand was sufficiently qualified to testify about the
general nature of K.L.’s condition, but she has no demonstrated competence or skill as an
immunologist. As a result, my embrace of the core of Petitioner’s theory requires acceptance of
her expert’s curatorial decisions in selecting various pieces of literature to support the theory –
despite the fact that Dr. Engstrand herself lacks expertise in the specific components of that theory,
such as studying cytokine upregulation and impact on the neurologic system. Despite the above, I
have given the theory consideration - but it did not gain persuasiveness simply because Dr.
Engstrand offered it.

    Beyond Dr. Engstrand’s qualifications, there is the issue of the reliability of the scientific basis
for Petitioner’s theory. While the individual articles offered proved reasonable and reliable
individually, taken as a whole they do not assist Petitioner’s case. Thus, much of the literature
offered either involved autoimmune forms of epilepsy (which are irrelevant under the facts of the
case), different vaccines, or involved the relationship between the HPV vaccine and febrile
seizures, which K.L. unquestionably never experienced. The epidemiologic evidence, such as the
Valencian Article, Crawford, and Spiczak, offered to suggest that afebrile seizures are also
possible not only involved VAERS-like passive surveillance (which is inherently less trustworthy
than a retrospective study observing actual diagnosed instances of illness or conditions like
epilepsy following vaccination)24 but was commonly distinguishable when examined closely.

    The proposed mechanism in this case – the impact of cytokines to cause neurologic injury, first
by impairing the blood-brain barrier, and then by attacking the brain and causing an afebrile seizure
- was an especially weak link in the theory. Although petitioners are not obligated to prove a
mechanism posited as a component of their causation theory (Knudsen, 35 F.3d at 548-49), the
evidence a claimant offers in support of that theory may reasonably be scrutinized. Althen, 418
F.3d at 1278. But the authority Dr. Engstrand offered to establish the scientific grounding for this
mechanism was insufficiently related to vaccines, or did not even facially support the concept. Li,
for example – an article that Petitioner only filed late in the case despite its prior availability –
involved the upregulation and impact of cytokines after, or in reaction to, a seizure – and thus tells
us nothing about whether they could cause a seizure in the first place. Li at 256.


24
     As another special master has commented in connection with the evidentiary value of VAERS reports,

           VAERS is a stocked pond. It only contains reports (many of which are unverified or incomplete) of adverse
           events after vaccinations. VAERS contains no reports or data about the relative rate of these same events in
           individuals who have not been vaccinated. Thus, the number of specific adverse events . . . reported after
           any vaccine, is meaningless without information about the background rate of that adverse event and
           information about the number of vaccines administered.

Tompkins v. Sec’y of Health and Human Servs., No. 10-261V, 2013 WL 3498652, at *16 (Fed. Cl. Spec. Mstr. June
21, 2013), review denied sub nom., Tompkins v. United States, 117 Fed. Cl. 713 (2014); see also Analla v. Sec’y of
Health & Human Servs., 700 Fed. Cl. 552, 558 (2006) (“[t]he Court uniformly has upheld . . . concerns about the
reliability of VAERS data”) (citations omitted).

                                                           19
    Dr. Engstrand’s effort to rehabilitate her opinion after its modification also reveals the
weakness at the theory’s heart. In her initial report, Dr. Engstrand proposed that cytokine IL-1 beta
was the primary cytokine involved in her proposed causation mechanism. First Engstrand Rep. at
4. In response, Dr. Shinnar noted that this cytokine was associated with fever – but K.L.
unquestionably had experienced an afebrile seizure, making it impossible for that particular
cytokine to have been involved in the alleged process by which the HPV vaccine causes K.L.’s
seizure. Ex. 4 at 52-53; Shinnar Rep. at 7; Tr. at 43. Dr. Shinnar further supported his position with
medical literature establishing that a wide number of cytokines beyond IL-1 beta would likely
cause fever if upregulated. See Gatti at 171.

         After the filing of Dr. Shinnar’s report, Dr. Engstrand attempted to bolster her opinion with
medical literature that purportedly showed instances of afebrile seizures following the HPV
vaccine, but on close inspection these were largely unpersuasive. The Valencian Article, for
example, makes no mention of whether the few reported instances of seizure were afebrile, leading
Dr. Engstrand to argue that they must have been because the authors would otherwise have
affirmatively noted the presence of a fever – a somewhat unreasonable inference. Tr. at 25. She
similarly referenced Li, which speaks more of the causative effect seizures have on the
upregulation of cytokines than the other way around, thus further undermining Dr. Engstrand’s
efforts to restore credibility to her theory after abandoning her initial opinion about the role of the
IL-beta cytokine.

         Respondent, by contrast, offered far more reliable and credible medical and scientific
articles suggesting the HPV vaccine would not likely cause injuries of the kind experienced by
K.L. Studies like Arnheim-Dahlstrom were more scientifically reliable (both given the larger
population groups studied, as well as the fact that they involved observed cases rather than simply
reported reactions) and more persuasively demonstrated no link between a number of neurological
events, including epilepsy, and receipt of the HPV vaccine. Arnheim-Dahlstrom at 4, 10 (Fig. 1).
In fact, Arnheim-Dahlstrom found that there was a higher incidence of seizure in those girls who
did not receive the HPV vaccine. Id. at 4, 8 (Table 2).

        Petitioner attempted to rebut such evidence with a few pieces of additional literature filed
post-hearing, but as already noted such items did not appreciably aid her case. Crawford, for
example, not only relied on data from a passive reporting system, but involved instances of post-
HPV vaccination afebrile seizures experienced by individuals with a “confirmed underlying
epilepsy disorder,” thus greatly reducing the probative quality of such findings when applied to
K.L., whose epilepsy is alleged to have begun only post-vaccination. Id. at 16. Spiczak, which
found that a statistically meaningful number of studied vaccinated individuals experiencing
afebrile seizures did so within approximately a week following vaccination (Spiczak at 1508), was




                                                  20
distinguishable because it did not involve the HPV vaccine. Id.25 Thus, the fact that other vaccines
can cause afebrile seizures provides weak proof for the proposition that the HPV vaccine did so in
this case – especially given the many other deficiencies in Petitioner’s theory already discussed.

    Vaccine Act claimants are not required to prove a causation theory to a scientific certainty, but
the theory must be based on “sound and reliable medical or scientific explanation.” Knudsen, 35
F.3d at 548. I do not find that Petitioner has satisfied this standard.

     B. Althen Prongs Two and Three

       Given my finding above, it is unnecessary to discuss Petitioner’s showings under the other
two Althen prongs. See, e.g., Veryzer v. Sec'y of Health & Human Servs., No. 06–522V, 2011 WL
1935813, at *17 (Fed. Cl. Spec. Mstr. Apr. 29, 2011), aff'd, 100 Fed. Cl. 344 (2011). I will
nevertheless briefly consider the evidentiary showing made by Petitioner for each of them.

         First, K.L. has not successfully demonstrated with preponderant evidence that the HPV
vaccine did cause her initial seizure as alleged, and thus has not satisfied the second Althen prong.
K.L.’s medical records indicated no signs of an autoimmune process occurring contemporaneous
with her initial hospitalization, or the kind of biologic markers that would reflect the cytokine
upregulation that Dr. Engstrand opined was happening herein. Rather, her test results throughout
treatment were normal, including an MRI and multiple EEGs. Dr. Shinnar also effectively
distinguished K.L.’s presentation with that of a patient with autoimmune epilepsy, who would
likely have displayed abnormal EEG results demonstrating the presence of a neurologic injury,
while at the same time being resistant to treatment. Tr. at 63. In addition, particularly trustworthy
treaters with significant epilepsy expertise, like Dr. Poduri, were aware of the vaccine’s
administration but concluded, based on their review of the developing medical record, that more
likely than not K.L.’s epilepsy was idiopathic. Ex. 3 at 17, 107, and 143, Ex. 9 at 11. Such evidence
was more persuasive than Dr. Engstrand’s statements to the contrary, and could not be rebutted by
contrary treater opinions that the vaccine was likely connected to K.L.’s epilepsy.

         Resolution of the third Althen prong is less easily accomplished. Dr. Engstrand’s theory
proposed that the cytokine upregulation would occur in the two-day timeframe at issue herein. It
is of course insufficient simply to rely on the temporal association between vaccine and injury to
satisfy this aspect of Althen. Grant v. Sec’y of Health & Human Servs., 956 F.2d 1144, 1148 (Fed.
Cir. 1992) (“a proximate temporal association alone does not suffice to show a causal link between


25
  Rather, Spiczak involved a number of common childhood vaccines— diphtheria- tetanus- acellular- pertussis, Hep.
B, measles, mumps, rubella, and the inactivated polio vaccine. Although Petitioner filed this medical literature as
Exhibit 43, she did not include the relevant supplemental references that were necessary for me to determine the
vaccines administered in the study. I consequently accessed the literature online and filed the supplemental
information as Court’s Exhibit 1.

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the vaccination and injury”). Dr. Engstrand was confronted with this at hearing, but confirmed that
her opinion did in fact place great weight on the temporal relationship. Tr. at 34.

        In addition, Dr. Engstrand offered little authority to support Petitioner’s conclusion that
this timeframe is “medically appropriate.” Indeed, the medical literature that Petitioner did offer
on this point is largely irrelevant to K.L. For example, Dr. Engstrand noted that the study in
Crawford had three participants that had experienced afebrile seizures between four hours and two
days after vaccination. Those three subjects, however, had an underlying epilepsy disorder, and
neither vaccine nor cytokine causation was proposed. Crawford at 16. Dr. Engstrand also presented
the Spiczak study, which reported that 17.8% of the children studied experienced afebrile seizures
with a median onset period of 48 hours. See Court’s Exhibit 1, fig. S1. But Spiczak did not include
the HPV vaccine, or patients above the age of seven for that matter. Id. At the same time, however,
I acknowledge that a two-day period between vaccination and seizure has been deemed medically
acceptable in other Program cases involving epilepsy (albeit not the HPV vaccine). L.A. v. Sec’y
of Health & Human Servs., No. 12-629, 2016 WL 7664473, at *15 (Fed. Cl. Spec. Mstr. Dec. 15,
2016) (“no difficultly in ascribing causation in a two-day interval” between receipt of Flumist and
the onset of seizures and encephalitis leading to a brain injury).

        None of the above constitutes particularly robust support for Petitioner’s proposed
timeframe – even though that timeframe is consistent with both the evidence and Petitioner’s
theory. Yet even were I to find that the balance of evidence on this matter barely favored K.L., that
determination would not alter my ultimate decision about causation, because Petitioner’s causation
theory itself is too deficient, and unsupported by the actual medical history. de Bazan v. Sec’y of
Health & Human Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008) (The explanation for what is a
medically acceptable timeframe must also coincide with the theory of how the relevant vaccine
can cause an injury (Althen prong one’s requirement)); see also, Shapiro v. Sec’y of Health &
Human Servs., 101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl. 353 (2012),
aff’d mem., 2013 WL 1896173 (Fed. Cir. 2013). At bottom, Petitioner’s theory is itself too
unreliable to put stock in the fact that timing as evidenced by the facts herein is consistent with
that theory.

                                         CONCLUSION


        The Vaccine Act permits me to award compensation only if a Petitioner alleging a
“non-Table Injury” can show by medical records or competent medical opinion that the injury
was more likely than not vaccine-caused. Here, the weight of the evidence does not support
Petitioner’s causation theory and there is insufficient evidence to support an award of
compensation, leaving me no choice but to hereby DENY this claim.

         In the absence of a timely-filed motion for review (see Appendix B to the Rules of the
 Court), the Clerk shall enter judgment in accord with this decision.
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IT IS SO ORDERED.

                         /s/ Brian H. Corcoran
                           Brian H. Corcoran
                           Special Master




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