Enrique C. Andreu and Sonia C. Andreu (“the Andreus”), on behalf of their son, Enrique M. Andreu (“Enrique”), appeal the judgment of the United States Court of Federal Claims affirming a special master’s decision denying their petition for compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-l to -34 (“Vaccine Act”).
See Andreu v. Sec’y of Health & Human Servs.,
No. 98-817V,
BACKGROUND
Enrique was born on September 5, 1995; he was a full-term baby, born after an uneventful pregnancy. On October 31, 1995, when he was eight weeks old, Enrique was inoculated with the diphtheria, whole-cell pertussis and tetanus (“DPT”) vaccine. Prior to this vaccination, Enrique was developing normally, although he had an ear infection and cold just prior to the time he was vaccinated.
Enrique cried a great deal throughout the evening of October 31, 1995. Jesus Gutierrez, Enrique’s great-grandfather, testified that on the next day, November 1, 1995, Enrique’s “left hand jumped for approximately one minute.” Enrique’s half-brother, Eric Andreu, also testified that he noticed Enrique’s arm making shaking movements on November 2, and November 6, 1995. On the evening of November 10, 1995, Enrique’s father observed Enrique’s unusual arm movements. The next day, the Andreus took Enrique to his pediatrician, who also observed Enrique’s arm movements. The pediatrician informed the Andreus that these movements were seizures, and arranged for Enrique to be taken to Miami Children’s Hospital (“MCH”). At the hospital, Enrique’s temperature was recorded at 99.4 degrees, and he was admitted for evaluation.
See Andreu v. Sec’y of Health & Human Servs.,
No. 98-817V,
On December 27, 1995, following his discharge from the hospital, Enrique was evaluated by Trevor Resnick, M.D., a pediatric neurologist. Resnick noted that Enrique continued to exhibit normal neurological development, but advised the An-dreus that he should not receive further pertussis vaccinations. Id. at *27-28.
Enrique experienced another seizure in February 1996. He remained seizure-free until October 1996, when he was hospitalized with febrile seizures. Id. at *29. Over the next month, Enrique continued to have seizures, which began with jerking arm movements and then became generalized. Id. at *30.
By January 1998, Enrique’s seizures had become “intractable and uncontrolled by medication.”
Court of Federal Claims Decision II,
The Andreus initiated their Vaccine Act claim on October 26,1998, alleging that the DPT vaccine Enrique received on October 31, 1995, caused his seizure disorder. On December 4, 2001, the Andreus submitted a letter from Marcel Deray, M.D., Enrique’s treating physician, who stated:
Enrique is a patient I have followed since 11/22/96. He has an encephalopathy and seizures. There has been no neurological cause found for his encephalopathy and no other explanation other than the DPT immunization given to him when he was an infant.
Enrique’s case was assigned to Special Master Richard Abell, who held an onset hearing to determine the date of Enrique’s first seizure. The special master found Gutierrez, Enrique’s great-grandfather, to be “a man of great personal dignity and honor,” and based upon his testimony, determined that Enrique’s first seizure occurred on November 1,1995, the day after he received the DPT vaccination. The case was subsequently transferred to Special Master Denise K. Vowell.
On November 28, 2005, the Andreus filed an expert report from Carlo Torna-tore, M.D., a neurologist. Tornatore opined that the DPT vaccination that Enrique received on October 31, 1995, “resulted in an acute encephalopathy and seizures secondary to the direct toxicity of the components in the whole-cell pertussis vaccine.” According to Tornatore, the DPT vaccine contains pertussis toxins and endotoxins, which can cross the brain-blood barrier, causing overstimulation of the nerves and supporting cells of the brain and provoking seizures. In support of his theory, Tornatore cited six articles showing that the pertussis toxin can be used to induce “excitotoxicity” in the brains of animals. In addition, Tornatore noted that persons infected with the pertussis virus can expei'ience encephalopathy and seizures and that this “wild-type infection is actually in some ways reproduced by the vaccination.”
In contrast, the government’s expert, Joel Herskowitz, M.D., asserted that Enrique’s seizure disorder was not caused by the DPT vaccine he received. Herskowitz
*1372
emphasized that the medical “literature does not support the occurrence of afebrile focal seizures as a consequence of a DPT whole-cell immunization.” In addition, although he acknowledged that Tornatore’s theory of causation was biologically plausible,
Vaccine Court Decision I,
On August 29, 2007, the special master issued a decision denying Enrique compensation. On March 3, 2008, however, the Court of Federal Claims reversed. The court held that “Dr. Tornatore’s expert report and testimony, standing alone, would meet the
Capizzano
requirements for recovery of compensation.”
Andreu v. Sec’y of Health & Human Servs.,
No. 98-817V,
On remand, the special master issued a subpoena compelling Enrique’s treating physicians, Deray and Resnick, to testify. Both doctors testified at a hearing held on April 28, 2008, in Miami, Florida. Resnick was asked by counsel for the government why he recommended that Enrique receive no further pertussis vaccinations. He responded that although he was “surmising,” he thought he had made this recommendation because “there was a concern over the relationship with the immunization, and I felt it would be safer for him not to have the pertussis, because there was a concern about a reaction.”
Resnick also testified that “[y]ou can see seizures within 24 hours of a vaccination, often in association with a fever, and that has been quite frequently reported epide-miologically.” He asserted, however, that the pertussis vaccine could “provoke” a seizure in a child who was “[n]ot behaving normally” or “really irritable” even in the absence of a fever. He further noted that in some instances “temperature isn’t measured,” so that to conclude that a seizure provoked by the DPT vaccine must be related to a fever is “somewhat unfair.” In addition, Resnick agreed that in Enrique’s case no one knows whether the first seizure was febrile or afebrile.
Deray testified that it was “still [his] opinion ... that there is no other explana *1373 tion for Enrique’s seizure disorder and encephalopathy other than the DPT vaccination.” Deray explained that there were two reasons that he had concluded that there was a causal connection between the vaccination and Enrique’s malady. First, although Deray could identify a cause for seizures in 70 to 75 percent of his patients, doctors, despite extensive testing, had “never found anything else” to explain Enrique’s seizures. Second, since the seizures occurred soon after the vaccination, Enrique’s “history would be consistent with [the] DPT immunization causing seizures.”
In addition, Deray asserted that whether Enrique’s initial seizures were febrile as opposed to afebrile would not influence his opinion that the DPT vaccine caused Enrique’s seizure disorder. In response to a question from the special master asking whether there was anything in either the SPECT scan or the MRI suggesting that the DPT vaccine caused Enrique’s seizures, Deray replied that whether or not the scans were normal “doesn’t help us either way.... You can have a normal MRI for the rest of your life and have brain damage.” On May 29, 2008, the special master issued a decision, again rejecting the Andreus’ claim for compensation under the Vaccine Act.
See Andreu v. Sec’y of Health & Human Servs.,
No. 98-817V,
On appeal, the Court of Federal Claims affirmed, concluding that the special master’s decision to deny compensation was not arbitrary or capricious. Although the court noted that even the government’s expert did not dispute the “biologic plausibility” of Tornatore’s theory of causation, the court stated that “the clinical evidence of record concerning Enrique’s seizures does not show the extent of initial injury sufficient to validate [the Andreus’] medical theory of DPT causation.”
Court of Federal Claims Decision II,
The Andreus then timely appealed to this court. We have jurisdiction under 42 U.S.C. § 300aa-12(f).
DISCUSSION
In reviewing an appeal from a judgment of the Court of Federal Claims in a Vaccine Act case, we apply the same standard of review as the Court of Federal Claims applied to the special master’s decision.
Capizzano,
“Childhood vaccinations, though an important part of the public health program, are not without risk. Because vaccines often contain either killed bacteria or live but weakened viruses, they can cause serious adverse effects.”
Terran v. Sec’y of Health & Human Servs.,
The Vaccine Act provides two separate mechanisms to obtain benefits: table claims and causation in fact claims. In a table claim, a claimant who shows that he or she received a vaccination listed in the Vaccine Injury Table (“table”), 42 U.S.C. § 300aa-14, and suffered an injury listed in the table within a prescribed period is afforded a presumption of causation. 42 U.S.C. § 300aa-11 (c)(1)(C)(i);
see Pafford v. Sec’y of Health & Human Servs.,
Because the Andreus cannot avail themselves of the table method of establishing causation, they must show that Enrique’s seizure disorder was “caused in fact” by the DPT vaccine he received.
See Capizzano,
Concisely stated, [a claimant’s] burden is to show by preponderant evidence that the vaccination brought about her 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 vaccination and injury. If [a claimant] satisfies this burden, she is entitled to recover unless the [government] shows, also by a preponderance of evidence, that the injury was in fact caused by factors unrelated to the vaccine.
*1375
The Andreus argue that they satisfied all three prongs of the Althen test by: (1) setting forth what even the government’s expert agreed was a “biologically plausible” theory explaining how toxins in the whole cell pertussis vaccine could cause seizures, (2) providing unequivocal testimony from Enrique’s treating physician that the DPT vaccine caused Enrique’s seizure disorder, and (3) establishing a medically appropriate temporal connection between Enrique’s DPT vaccination and his first seizure. We agree.
Three fundamental errors infected the special master’s decision to deny Enrique compensation. First, the special master incorrectly determined that the testimony of Enrique’s treating physicians was insufficient to establish “a logical sequence of cause and effect” between the DPT vaccine Enrique received on October 31, 1995, and the seizure he experienced one day later. Second, she imposed upon the Andreus an elevated evidentiary burden, requiring them to submit conclusive proof in the medical literature linking afebrile seizures to components in the whole-cell pertussis vaccine. Finally, the special master erroneously determined that Enrique’s “clinical picture” precluded a finding that his seizure disorder was caused by an injury to the brain from the DPT inoculation.
I. Testimony from Treating Physicians
There is no dispute that the Andreus met the first and third prongs of the
Al-then
test. The first prong was satisfied because Tornatore, the Andreus’ expert, presented a “biologically plausible” theory establishing that toxins in the whole-cell pertussis vaccine can cause seizures.
1
Court of Federal Claims Decision II,
If a claimant satisfies the first and third prongs of the
Althen
standard, the second prong can be met through medical opinion testimony.
Capizzano,
Here, the testimony of Deray, the pediatric neurologist who has treated Enrique since 1996, was sufficient to establish a
*1376
logical sequence of cause and effect between the DPT vaccine Enrique received on October 31, 1995, and the seizure he experienced the next day. Deray stated unequivocally that he believed that the DPT inoculation caused Enrique’s seizures, and explained that there were “[t]wo things” which caused him to reach this conclusion. First, although he was able to identify a cause for seizures in 70 to 75 percent of his patients, Deray had found no cause — other than the DPT vaccination — to explain the seizures that Enrique experienced.
See Liable,
The testimony of Resnick, the admitting neurologist at the time of Enrique’s initial hospitalization at MCH, was not as unequivocal as that of Deray, but, read as a whole, also supports a causal connection between the DPT vaccine and Enrique’s November 1, 1995, seizure. Resnick testified that “[y]ou can see seizures within 24 hours of a vaccination, often in association with a fever, and that has been quite frequently reported epidemiologically.” Res-nick acknowledged, however, that the pertussis vaccine can provoke seizures even in the absence of a fever, 2 in situations where a child is “really irritable” or “[n]ot behaving normally.” He further asserted that it is “unfair” to focus on whether or not a child has a fever at the time of a seizure because “sometimes temperature isn’t measured” at that time.
Resnick acknowledged, moreover, that in 1995, shortly after Enrique was released from MCH, he had advised the Andreus that Enrique should receive no further pertussis vaccinations. Resnick testified that although he was just being “conservative,” he made this recommendation because “there was a concern over the relationship [of the seizures] with the immunization, and I felt it would be safer for [Enrique] not to have the pertussis, because there was a concern about a reaction.” A treating doctor’s recommendation to withhold a particular vaccination can provide probative evidence of a causal link between the vaccination and an injury a claimant has sustained.
3
See Capizzano,
II. Conclusive Proof in the Medical Literature
The special master likewise erred in requiring that the Andreus provide conclusive evidence in the medical literature linking afebrile seizures to the DPT vaccine. The Andreus’ expert witness, Torna-tore,
4
testified that it was his opinion that Enrique’s “whole-cell pertussis vaccination of October 31, 1995, resulted in an acute encephalopathy and seizures secondary to the direct toxicity of the components in the whole-cell pertussis vaccine.” As the special master acknowledged, Tornatore’s theory of causation is premised on “the unassailable position that the DPT vaccination Enrique received contained pertussis toxin and endotoxin.”
Vaccine Court Decision I,
Herskowitz, the government’s lone expert witness, did little to cast doubt on Tornatore’s theory of causation. To the contrary, he “did not dispute the biologic plausibility of Dr. Tornatore’s medical theory,”
Court of Federal Claims Decision II,
Furthermore, there is a real question as to whether Enrique’s first seizure was febrile or afebrile.
6
Because Enrique’s temperature apparently was not taken at the time of his initial seizure, we have no way of knowing whether it was elevated or not. Herskowitz, the government’s expert, testified that a “febrile” seizure could occur in a child who had a temperature just one degree above normal.
7
Thus, it is quite possible that Enrique had a low-grade fever in the period immediately after his vaccination, but that this fever went either unnoticed or unreported by his family members. Indeed, when Enrique was taken to the hospital on November 11, 1995, his temperature, recorded at 99.4 degrees,
see Vaccine Court Decision I,
Even assuming
arguendo
that Enrique’s initial seizure was afebrile, however, the special master erred in requiring conclusive evidence in the medical literature linking the DPT vaccine to afebrile seizures. Requiring “epidemiologic studies ... or general acceptance in the scientific or medical communities ... impermis-sibly raises a claimant’s burden under the Vaccine Act and hinders the system created by Congress, in which close calls regarding causation are resolved in favor of injured claimants.”
Capizzano,
Prior to
Althen,
special masters applied the so-called
Stevens
test to determine whether a vaccine caused a claimant’s injury.
See Stevens v. Sec’y of Health & Human Servs.,
No. 99-594V,
The special master framed her rejection of Tornatore’s theory of causation under the rubric of a “credibility” determination.
See Vaccine Court Decision II,
III. Standards for Assessing Medical Literature and Epidemiological Evidence
Although
Althen
and
Capizza-no
make clear that a claimant need not produce medical literature or epidemiological evidence to establish causation under the Vaccine Act, where such evidence is submitted, the special master can consider it in reaching an informed judgment as to whether a particular vaccination likely caused a particular injury.
See Daubert,
The standard of proof required by the [Vaccine] Act is simple preponderance of evidence; not scientific certainty.... [I]t is not plaintiffs burden to disprove every possible ground of causation suggested by defendant nor must the findings of the court meet the standards of the laboratorian.
Bunting v. Sec’y of Health & Human Servs.,
In medical research, “attribution of causation is typically not made until a level of
very near certainty
— perhaps 95% probability — is achieved.”
Liable,
IV. Enrique’s Clinical Picture
We also disagree with the special master’s determination that Enrique’s “clinical picture” was inconsistent with a toxic injury to the brain from the pertussis vaccine. Herskowitz, the government’s expert witness, acknowledged that the pertussis antigen can cause neurotoxicity.
Vaccine Court Decision
I,
In response to questioning from Enrique’s attorney, however, Herskowitz acknowledged that if the pertussis vaccine could cause a “devastating encephalopathy,” it could “also cause a smaller amount of brain injury in a smaller area of the brain.” Notably, Herskowitz did not assert that it would be impossible for the pertussis toxin to injure one area of Enrique’s brain while at the same time leaving other areas unscathed.
Neither the special master nor the Court of Federal Claims is “to be seen as a vehicle for ascertaining precisely how and why [the DPT vaccine] sometimes destroy[s] the health and lives of certain children while safely immunizing most others.”
Knudsen,
Likewise, the fact that Enrique met developmental milestones for a period after his initial seizures is not inconsistent with Tornatore’s postulated mechanism of causation. Presumably, Enrique’s initial seizures, which were relatively brief, had little impact on his neurological development, but subsequent seizures, which “became intractable and uncontrolled by medication,” caused much more significant cognitive deficits.
See Lurtz v. Sec’y of Health & Humans Servs.,
No. 90-1703V,
In cases of severe seizure disorders, the initial MRI is more commonly negative than it is positive, regardless of the cause of the disorder. In vaccine injury, both MRI’s and CT scans will be normal initially. Over the years, one might expect to observe cerebral atrophy, but one would not observe it right away. Customarily, one will observe no immediate markers to identify a DPT injury other than its clinical course.... If the condition continues, pathology can be later identified ... but would not indicate what caused the injuries.
Id.
at *31,
The DPT vaccine leaves no “footprint” evidencing that it was the catalyst for a particular injury.
Almeida,
V. Compelling Physician Testimony
As a final matter, we address the Andreus’ argument that the special master erred in requiring testimony from Enrique’s treating physicians. Under 42 U.S.C. § 300aa-12(d)(3)(B)(iii), the special master has the right to “require the testimony of any person and the production of any documents as may be reasonable and necessary.” Because: (1) the Andreus placed the testimony of Enrique’s treating physicians at issue by relying on their statements to support a determination of causation, and (2) there was ambiguity surrounding certain statements made by the *1383 physicians, the special master did not abuse her discretion in requiring Deray and Resnick to testify.
Although the Federal Rules of Evidence provide for a physician-patient privilege if it is available under state law, see Fed. R.Evid. 501, those rules are not applicable in Vaccine Court proceedings.
See
U.S.Ct. Fed. Cl. R., Vaccine Rule 8(b) (“In receiving evidence, the special master will not be bound by common law or statutory rules of evidence.”). In most instances, however, it is both inadvisable and unnecessaiy to subpoena the testimony of treating physicians. It would not be in the public interest for the specter of a subpoena to provide physicians with a disincentive to treat a vaccine-injured patient or to cause them to be less than forthright in creating medical records assessing the relationship between a vaccine and a patient’s injury. The submitted documentary evidence can, under most circumstances, provide adequate insight into the medical opinions of treating physicians, and there is little need to subject them to cross-examination in federal court. See
Cucaras v. Sec’y of Health & Human
Servs.,
Requiring treating physicians to testify in Vaccine Act cases is likely to serve only to prolong and increase the adversarial nature of proceedings, contrary to Congress’ objective to create a federal compensation scheme under which awards are made to “vaccine-injured persons quickly, easily, and with certainty and generosity.” H.R.Rep. No. 99-908, at 3 (1986), 1986 U.S.C.C.A.N. at 6344;
see also
135 Cong. Rec. 16,555 (daily ed. Nov. 6, 1989) (statement of Sen. Kennedy) (“We also reiterate our expectation that the special master and the powers given to the special master will allow the proceedings to be direct and straightforward. The special master should be able to require from petitioners and respondents information sufficient to evaluate the petition without resort to complex proceedings.”);
Knudsen,
CONCLUSION
Accordingly, the judgment of the Court of Federal Claims is reversed and the case is remanded for an assessment of damages.
COSTS
Appellants shall have their costs.
REVERSED AND REMANDED.
Notes
. In recent years, most children in the United States have been inoculated with the DTaP vaccine, which contains an acellular pertussis component, as opposed to the DPT vaccine, which contains a whole-cell pertussis component.
See Vaccine Court Decision I,
. In response to questioning from Enrique's counsel, Resnick gave the following testimony at the remand hearing:
Q: But it is your understanding that pertussis can produce seizures in the absence of fever, is that correct?
A: It can, because — first of all, all the time people don't measure the seizures so— Q: The fever, you mean?
A: Don't measure the fever. So you have a history where there’s an event that occurs, the fever isn't measured, and I would call that a provoked seizure.
. Although Resnick noted that epidemiological evidence indicates that reactions to the DPT vaccine often include fever and irritability, he never asserted that he did not believe that Enrique's seizures were the result of the DPT vaccination he received on October 31, 1995. To the contrary, Resnick testified that he thought it would be "safer” for Enrique not to receive additional pertussis inoculations because there was "some evidence” to indicate that Enrique had had a reaction to the vaccine. In other words, Resnick thought that there was "some evidence" to indicate *1377 that Enrique's initial seizure was a "reaction" to the DPT vaccine.
. As the Court of Federal Claims correctly recognized, Tornatore has "excellent medical credentials.”
Court of Federal Claims Decision I,
. Tornatore "explained [his] theory by analogizing nerves to electrical wires; when the nerves become excited, they produce excess electricity, a manifestation of which is a seizure.”
Vaccine Court Decision I,
. "The term 'afebrile' literally means ‘without fever,' so that the term ‘afebrile seizure' seems to refer to a seizure that is not accompanied by an above normal body temperature.”
Liable,
. Herskowitz explained that "[t]he normal Fahrenheit temperature is 98.6 rectally,” so if a child has a temperature one degree higher than that when he experiences a seizure, the seizure could be considered febrile.
. The special master refused to credit evidence from the NCES because she did not believe that Enrique would have qualified as an NCES “case child.”
Vaccine Court Decision I,
. The special master criticized Tornatore for relying upon animal studies to show that the pertussis toxin can cause injuiy to brain tissue.
Vaccine Court Decision II,
. Wc thus refuse to accept the government's assertion that the fact that the MRI scan of Enrique's brain was normal in the period immediately following his initial seizures precludes a finding of causation. As the special master correctly acknowledged, 'Ta] child may have chronic seizures without ... MRI evidence of injury.”
Vaccine Court Decision I,