[Federal Register Volume 85, Number 139 (Monday, July 20, 2020)]
[Proposed Rules]
[Pages 43794-43805]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-15673]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

42 CFR Part 100

RIN 0906-AB24


National Vaccine Injury Compensation Program: Revisions to the 
Vaccine Injury Table

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services (HHS).

ACTION: Notice of proposed rulemaking.

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SUMMARY: The Secretary proposes to amend the Vaccine Injury Table 
(Table) by regulation. The proposed regulation will have effect only 
for petitions for compensation under the National Vaccine Injury 
Compensation Program (VICP) filed after the final regulations become 
effective. HHS is seeking public comment on the proposed revisions to 
the Table.

DATES: Written comments and related material to this proposed rule must 
be received to the online docket via www.regulations.gov on or before 
January 12, 2021.

ADDRESSES: Comments must be identified by HHS Docket No. HRSA-2020-
0002. Because of staff and resource limitations, comments must be 
submitted electronically to www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including personally identifiable or confidential business information 
that is included in a comment. You may wish to consider limiting the 
amount of personal information that you provide in any voluntary public 
comment submission you make. HHS may withhold information provided in 
comments from public viewing that it determines may impact the privacy 
of an individual or is offensive. For additional information, please 
read the Privacy Act notice that is available via the link in the 
footer of http://www.regulations.gov.
    Follow the search instructions on that website to view the public 
comments.

FOR FURTHER INFORMATION CONTACT: Please visit the National Vaccine 
Injury Compensation Program's website, https://www.hrsa.gov/vaccinecompensation/, or contact Tamara Overby, Acting Director, 
Division of Injury Compensation Programs, Healthcare Systems Bureau, 
HRSA, Room 08N146B, 5600 Fishers Lane, Rockville, MD 20857; by email at 
[email protected]; or by telephone at (855) 266-2427.

SUPPLEMENTARY INFORMATION: This is a notice of proposed rulemaking by 
which HHS proposes to amend the provisions of 42 CFR 100.3 by removing 
Shoulder Injury Related to Vaccine Administration, vasovagal syncope, 
and Item XVII from the Vaccine Injury Table.

I. Public Participation

    All interested parties are invited to participate in this 
rulemaking by submitting written views, comments and arguments on all 
aspects of this proposed rule, as well as additional data that should 
be considered. HHS also invites comments that relate to the economic, 
legal, environmental, or federalism effects that might result from this 
proposed rule. Comments that will provide the most assistance to HRSA 
in implementing these changes will reference a specific portion of the 
proposed rule, explain the reason for any recommended change, and 
include data, information, or authority that supports such recommended 
change.
    A public hearing on this proposed rule will be held before the end 
of the public comment period. A separate document will be published in 
the Federal Register providing details of this hearing. Subject to 
consideration of the comments received, the Secretary intends to 
publish a final regulation.
    Instructions: If you submit a comment, you must include the agency 
name and the HHS Docket No. HRSA-2020-0002 for this rulemaking. All 
submissions will be posted, without change, to the Federal eRulemaking 
Portal at http://www.regulations.gov, and will include any personal 
information you provide. Therefore, submitting this information makes 
it public. You may wish to consider limiting the amount of personal 
information that you provide in any voluntary public comment submission 
you make to HHS. HHS may withhold information provided in comments from 
public viewing that it determines may impact the privacy of an 
individual or is offensive. For additional information, please read the 
Privacy Act notice that is available via the link in the footer of 
http://www.regulations.gov.

II. Background and Purpose

    Vaccination is one of the best ways to protect against potentially 
harmful diseases that can be very serious, may require hospitalization, 
or even be deadly. Almost all individuals who are vaccinated have no 
serious reactions.\1\ Nonetheless, in the 1980s, Congress became 
concerned that a small number of children who received immunizations 
had serious reactions to them, and it was not always possible to 
predict which children would have reactions, or what reactions they 
would have.\2\ Claimants alleging vaccine-related injuries in civil 
litigation encountered a time-consuming, expensive, and often 
inadequate system.\3\ Moreover, increased litigation against vaccine 
manufacturers resulted in difficulties in their ability to secure 
affordable product liability insurance, stabilize vaccine prices and 
supply, and enter the market.\4\
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    \1\ National Vaccine Injury Compensation Program, Health 
Resources & Servs. Admin., https://www.hrsa.gov/vaccine-compensation/index.html (last reviewed Jan. 2020).
    \2\ H.R. Rep. No. 99-908, pt. 1, at 6 (1986). Even though in 
rare instances individuals may have adverse reactions to vaccines, 
the Centers for Disease Control and Prevention (CDC) recommends that 
individuals be vaccinated against a wide range of illnesses and 
diseases. See Recommended Vaccines by Age. Ctrs. for Disease Control 
& Prevention, https://www.cdc.gov/vaccines/vpd/vaccines-age.html 
(last reviewed Nov. 22, 2016).
    \3\ H.R. Rep. No. 99-908, at 6.
    \4\ See id. at 4-6.
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    Therefore, Congress enacted the National Childhood Vaccine Injury 
Act of 1986, title III of Public Law 99-660 (42 U.S.C. 300aa-1 et seq.) 
(Vaccine Act), which established the National Vaccine Injury 
Compensation Program (VICP). The objectives of the VICP are to ensure 
an adequate supply of vaccines, stabilize vaccine costs, and establish 
and maintain an accessible and efficient forum for individuals found to 
be injured by certain vaccines to be federally compensated. Petitions 
for compensation under the VICP are filed

[[Page 43795]]

in the United States Court of Federal Claims (Court), rather than the 
civil tort system, with a copy served on the Secretary, who is the 
Respondent. The U.S. Department of Justice (DOJ) represents HHS in 
Court, and the Court, acting through judicial officers called Special 
Masters, makes the final decision as to eligibility for, and the type 
and amount of, compensation.
    To gain entitlement to compensation under this Program, a 
petitioner must establish that a vaccine-related injury or death has 
occurred, either by proving that a vaccine actually caused or 
significantly aggravated an injury (causation-in-fact) or by 
demonstrating what is referred to as a ``Table injury.'' That is, a 
petitioner may show that the vaccine recipient (1) received a vaccine 
covered under the Act; (2) suffered an injury of the type enumerated in 
the regulations at 42 CFR 100.3-the ``Vaccine Injury Table'' (Table)--
corresponding to the vaccination in question; and (3) that the onset of 
such injury took place within the time period specified in the Table. 
If so, the injury is presumed to have been caused by the vaccine, and 
the petitioner is entitled to compensation (assuming that other 
requirements are satisfied), unless the respondent affirmatively shows 
that the injury was caused by some factor unrelated to the vaccination 
(see 42 U.S.C. 300aa-11(c)(1)(C)(i), 300aa-13(a)(1)(B), and 300aa-
14(a)).
    42 U.S.C. 300aa-14(c) and (e) permit the Secretary to revise the 
Table. The Table currently includes 17 vaccine categories, with 16 
categories for specific vaccines, as well as the corresponding 
illnesses, disabilities, injuries, or conditions covered, and the 
requisite time period when the first symptom or manifestation of onset 
or of significant aggravation after the vaccine administration must 
begin to receive the Table's legal presumption of causation. The final 
category of the Table, ``Item XVII,'' includes ``[a]ny new vaccine 
recommended by the Centers for Disease Control and Prevention for 
routine administration to children, after publication by the Secretary 
of a notice of coverage.'' \5\ Two injuries--Shoulder Injury Related to 
Vaccine Administration (SIRVA) and vasovagal syncope--are listed as 
associated injuries for this category. Through this general category, 
new vaccines recommended by the CDC for routine administration to 
children and subject to an excise tax are deemed covered under the VICP 
prior to being added to the Table as a separate vaccine category 
through Federal rulemaking.
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    \5\ 42 CFR 100.3(a).
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    On January 19, 2017, the Department issued a final rule amending 
the Table (Final Rule) that, among other things, added SIRVA and 
vasovagal syncope to the Table. 85 FR 6294. That Final Rule was 
scheduled to take effect on February 21, 2017. A notice published in 
the Federal Register delayed the effective date until March 21, 2017. 
82 FR 11321. The Final Rule followed a 2012 Institute of Medicine (IOM) 
\6\ report, ``Adverse Effects of Vaccines: Evidence and Causality;'' 
the work of nine HHS workgroups that reviewed the IOM findings; and 
consideration of the Advisory Commission on Childhood Vaccines' (ACCV) 
recommendations.
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    \6\ The IOM is now known as the National Academy of Medicine.
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    The Department now proposes to remove SIRVA and vasovagal syncope 
from the Table found at 42 CFR 100.3(a) and to remove the corresponding 
descriptions of those injuries--``Qualifications and Aids to 
Interpretation'' (QAI)--from 42 CFR 100.3(c). This proposal is based 
upon a review of the relevant statutory provisions and the scientific 
literature, as well as the Department's experience since SIRVA and 
vasovagal syncope were added to the Table. The Department also proposes 
to remove Item XVII from the Table found at 42 CFR 100.3(a), because 
the Department has serious concerns that Item XVII is contrary to 
applicable law, for the reasons set forth below.

Scientific Literature Concerning SIRVA and Vasovagal Syncope

    The scientific literature indicates that SIRVA likely results from 
poor vaccination technique, rather than the vaccine or its components 
alone. The notice of proposed rulemaking that preceded the Final Rule 
characterized SIRVA as an ``adverse event following vaccination thought 
to be related to the technique of intramuscular percutaneous injection 
(the procedure where access to a muscle is obtained by using a needle 
to puncture the skin) into an arm resulting in trauma from the needle 
and/or the unintentional injection of a vaccine into tissues and 
structures lying underneath the deltoid muscle of the shoulder.'' \7\ 
The IOM similarly concluded that ``the injection, and not the contents 
of the vaccine, contributed to the development of deltoid bursitis.'' 
\8\ Indeed, the primary case series relied upon by the Department in 
promulgating the proposed rule and Final Rule found that the medical 
literature supports the possibility that SIRVA may result from 
inappropriate needle length and/or injection technique.\9\ There is 
nearly uniform agreement in the scientific community that SIRVA is 
caused by improper vaccine administration, rather than by the vaccine 
itself.\10\ Since the Final Rule was promulgated, additional scientific 
research concluded that subdeltoid or subacromial bursitis and other 
shoulder lesions are ``more likely to be the consequence of a poor 
injection technique (site, angle, needle size, and failure to take into 
account [a] patient's characteristics, i.e., sex, body weight, and 
physical constitution),'' rather than ``antigens or adjuvants contained 
in the vaccines that would trigger an immune or inflammatory 
response.'' \11\
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    \7\ National Vaccine Injury Compensation: Revision to the 
Vaccine Injury Table (``2015 Proposed Rule''), 80 FR 45132, 45136 
(July 29, 2015) (emphasis supplied); see also Adverse Effects of 
Vaccines: Evidence and Causality (``IOM Report''), at 620, available 
at https://www.nap.edu/catalog/13164/adverse-effects-of-vaccines-evidence-and-causality.
    \8\ IOM Report at 620. SIRVA is a medicolegal term, not a 
medical diagnosis, that is meant to capture a broad array of 
potential shoulder injuries. However the IOM only made findings 
concerning deltoid bursitis.
    \9\ Atanasoff S, Ryan T, Lightfoot R, and Johann Liang R, 2010, 
Shoulder injury related to vaccine administration (SIRVA), Vaccine 
28(51): 8049-52 (recommending that injections avoid the top third of 
the deltoid muscle to avoid shoulder injury).
    \10\ See Barnes MG, Ledford C, Hogan K. A ``needling'' problem: 
Shoulder injury related to vaccine administration. J Am Board Fam 
Med. 2012 Nov-Dec; 25(6):919-22; Cross GB, Moghaddas J, Buttery J, 
Ayoub S, Korman TM. Don't aim too high: Avoiding shoulder injury 
related to vaccine administration. Aust Fam Physician. 2016 May; 
45(5):303-6.
    \11\ Mart[iacute]n Arias, K.H., Fadrique, R., S[aacute]inz Gil, 
M., and Salgueiro-Vazquez, M.E., Risk of bursitis and other injuries 
and dysfunctions of the shoulder following vaccinations, Vaccine, 
2017; 35: 4870-4876. See also Bancsi A, Houle SKD, Grindrod KA. 
Shoulder injury related to vaccine administration and other 
injection site events. Can. Fam. Physician. 2019 Jan; 65(1): 40-42 
(explaining that SIRVA ``is a preventable occurrence caused by the 
injection of a vaccine into the shoulder capsule rather than the 
deltoid muscle''); Macomb CV, Evans MO, Dockstater JE, Montgomery 
JR, Beakes DE. Treating SIRVA Early With Corticosteroid Injections: 
A Case Series. Mil Med. 2019 Oct 17 (noting that SIRVA does not 
occur unless the vaccine is mistakenly given in the shoulder 
capsule). Another recent study reviewed the Vaccine Adverse Event 
Reporting System (VAERS) database from July 2010 to June 2017 for 
reports of atypical shoulder pain and dysfunction following 
injection of inactivated influenza vaccine (IIV). See B. F. Hibbs, 
C. S. Ng, O. Museru et al., Reports of atypical shoulder pain and 
dysfunction following inactivated influenza vaccine, Vaccine Adverse 
Event Reporting System (VAERS), 2010-2017, Vaccine. The review found 
that, of the 266 reports where contributing factors for the injury 
were reported, 216 (81.2%) described the vaccination as being given 
``too high'' on the arm. Other reports described improper or poor 
administration technique (e.g., bone strikes, ``administered in 
tendon''), uneven position between vaccinator and the patient (e.g., 
vaccinator standing while patient sitting), vaccination needle too 
long, and others (e.g., difficulty injecting vaccine). A small 
minority of reports also indicated the patient had a history of 
thyroid dysfunction or diabetes.
    It is possible that certain injuries characterized as SIRVA 
occur when an immunologically active substance designed to trigger 
an inflammatory response (i.e., the vaccine antigen) is injected 
into an area where the inflammatory response can cause joint damage 
(i.e., the bursa or tendons) as opposed to an area where the 
inflammatory response will not cause joint damage or permanent harm 
(i.e., the deltoid muscle). Such injuries are fairly characterized 
as resulting from the vaccination technique, since they would not 
have occurred if the injection occurred in the proper part of the 
body.

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[[Page 43796]]

    The scientific literature also indicates that vasovagal syncope 
results from the act of injection, rather than the vaccine or its 
components. Vasovagal syncope is the loss of consciousness (fainting) 
caused by a transient decrease in blood flow to the brain.\12\ In 
proposing the addition of vasovagal syncope to the Table, the 
Department noted that the IOM found that syncope did not result from 
any particular antigen, but instead from the act of the injection.\13\ 
The scientific literature suggests that those administering vaccines 
can take steps to significantly reduce the likelihood of injury from 
vasovagal syncope, such as having the patient sit or lie down for the 
vaccination, and observing the patient for 15 to 20 minutes after 
administering the vaccine.\14\
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    \12\ 82 FR 6294-01, 6304 (Jan. 19, 2017).
    \13\ 80 FR 45137 (The IOM found that one case report suggested 
that ``the injection, and not the contents of the vaccine, 
contributed to the development of syncope''). See also IOM Report at 
18 (``injection of vaccine, independent of the antigen involved, can 
lead to'' syncope).
    \14\ Miller, E. and Woo, E.J. 2006 Time to prevent injuries from 
postimmunization syncope, Nursing, 36 (12): 20; Braun, M., 
Patriarca, P., and Ellenberg, S. Syncope After Immunization, Arch. 
Pediatr. Adolesc. Med. 1997; 151: 255-259.
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Reasons for Removal of SIRVA and Vasovagal Syncope

    The Department has concluded that several reasons merit removal of 
SIRVA and vasovagal syncope from the Table found at 42 CFR 100.3(a), 
and to correspondingly remove the descriptions of those injuries from 
the QAI found at 42 CFR 100.3(c).
    First, the Department has concluded that the Vaccine Act should be 
read as not applying to cover injuries, like SIRVA and vasovagal 
syncope, which involve negligence by the vaccine administrator. At 
best, the Vaccine Act is ambiguous in how it handles such injuries, and 
in the Department's view there are strong reasons to exclude them from 
coverage under the Act's compensation scheme.
    The Act creates a compensation program ``for a vaccine-related 
injury or death.'' 42 U.S.C. 300aa-11(a)(1). Under the Act, ``only . . 
. a person who has sustained a vaccine-related injury or death'' can 
recover. 42 U.S.C. 300aa-11(a)(9). The Act defines ``[v]accine-related 
injury or death'' as ``an illness, injury, condition, or death 
associated with one or more of the vaccines set forth in the Vaccine 
Injury Table, except that the term does not include an illness, injury, 
condition, or death associated with an adulterant or contaminant 
intentionally added to such a vaccine.'' 42 U.S.C. 300aa-33(5) 
(emphasis added); see also Dean v. HHS, No. 16-1245V, 2018 WL 3104388, 
at * 9 (Fed. Cl. Spec. Mstr. May 29, 2018) (defining ``vaccine'' as 
```any substance designed to be administered to a human being for the 
prevention of 1 or more diseases''') (quoting 26 U.S.C. 4132(a)(2)). 
Thus, the compensation program covers injuries ``associated with'' the 
vaccine itself.
    SIRVA is, of course, not a vaccine, and it is not an injury caused 
by a vaccine antigen, but by administration of the vaccine by the 
health care provider. The Department does not think the term 
``associated with'' was meant to sweep in injuries caused by negligent 
administration of the vaccine. Although the Act permits petitioners to 
recover for Vaccine Table injuries without demonstrating causation in 
individual cases, the term ``associated with'' nevertheless requires 
that the injury, in general, be causally related to the vaccine itself. 
This is clear both from dictionary definitions of ``associated,'' which 
means ``related, connected, or combined together'' (Merriam-Webster.com 
Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/associated. Accessed 10 Jul. 2020), and from the text of the 
Act itself, see, e.g., 42 U.S.C. 300aa-22(b)(1) (focusing on injuries 
that ``resulted'' from vaccine side effects); 42 U.S.C. 300aa-
13(a)(1)(B) & (2)(B) (excluding ``trauma'' that has ``no known relation 
to the vaccine involved''). Importantly, in the key operative 
provisions discussed above, the phrase ``associated with'' is linked to 
the vaccine itself, not to the technique in administering the vaccine. 
See Decker v. Nw. Envtl. Def. Ctr., 568 U.S. 597, 611 (2013) (in 
interpreting phrase ``associated with industrial activity,'' the key 
consideration is the scope of ``industrial activity''; the ``statute 
does not foreclose a more specific definition by the agency'' and ``a 
reasonable interpretation . . . could . . . require the discharges to 
be related in a direct way to operations at `an industrial plant' ''); 
Chevron, U.S.A., Inc. v. Nat. Resources Def. Council, Inc., 467 U.S. 
837, 861 (1984) (``[T]he meaning of a word must be ascertained in the 
context of achieving particular objectives, and the words associated 
with it may indicate that the true meaning of the series is to convey a 
common idea.'').
    That basic requirement is not met with SIRVA and vasovagal syncope. 
While the act of being vaccinated may be a but-for cause of those 
injuries, the injury is not associated with the vaccine itself because, 
with proper administration technique, those injuries will not result 
from the vaccine. Rather, SIRVA and vasovagal syncope result from the 
use of improper--that is, negligent--administration technique. 
Furthermore, to the extent there is ambiguity about the scope of 
injuries encompassed by the phrase ``associated with,'' this reading, 
grounded in tort law principles, better achieves the Act's objectives 
for the reasons below.
    There are several indicators in the language and structure of the 
Vaccine Act that show it was not meant to cover negligent 
administration of the vaccine. First, as the Federal Circuit has 
explained, troubling issues arise if the Act were to apply to 
``negligence facially unrelated to the vaccine's effects.'' Amendola v. 
Sec., Dept. of Health & Human Servs., 989 F.2d 1180, 1187 (Fed. Cir. 
1993). It could include, for example, ``the doctor's negligent dropping 
of an infant patient'' or use of contaminated equipment. Id. at 1186-
87. The better reading of the statute is that it does not reach this 
far.
    Second, the definition of vaccine-related injury carves out ``an 
adulterant or contaminant intentionally added to such a vaccine. 42 
U.S.C. 300aa-33(5) (emphasis added). By excluding from the definition 
those injuries associated with an adulterant or contaminant 
intentionally added to the vaccine, Congress indicated its intent to 
permit suit only where the injury was caused by the components of the 
vaccine itself, not individual fault. Relatedly, in the provisions 
setting forth the standard for awarding compensation, Congress 
specified that an award is not appropriate when injury was ``due to 
factors unrelated to the administration of the vaccine,'' and further 
defined that phrase to include ``trauma . . . which have no known 
relation to the vaccine involved.'' 42 U.S.C. 300aa-13(a)(1)(B) & 
(2)(B). In other words, Congress excluded compensation for injuries 
that were not related ``to the vaccine involved.''
    Third, the statutory scheme requires that the patient ``received a 
vaccine set forth in the Vaccine Injury Table,'' 42

[[Page 43797]]

U.S.C. 300aa-11(c)(1)(A), tying compensation to the receipt of a 
specific listed vaccine. See 42 U.S.C. 300aa-11(c)(1)(C)(i) (speaking 
to an injury aggravated ``in association with the vaccine referred to'' 
on the Vaccine Injury Table); 42 U.S.C. 300aa-11(c)(1)(C)(ii)(I) (for 
conditions not on the Vaccine Injury Table, allowing proof that the 
condition ``was caused by a vaccine'' on the Table); 42 U.S.C. 300aa-
11(c)(1)(C)(ii)(II) (same). But negligent administration can occur 
without regard to the specific vaccine and, as noted above, can 
encompass anything from negligent needle placement to ``the doctor's 
negligent dropping of an infant patient.'' Amendola, 989 F.2d at 1186-
87. Congress strongly signaled that it was focused on compensation for 
harm caused by the vaccine by requiring that the Table list the 
vaccines themselves and the types of injuries the vaccines themselves 
would cause.
    Fourth, in the provision preempting state tort liability, Congress 
protected manufacturers from liability when the injury ``resulted from 
side effects that were unavoidable even though the vaccine was properly 
prepared. . .'' 42 U.S.C. 300aa-22(b)(1). This language shows Congress 
wanted to preserve a state tort remedy for certain avoidable injuries, 
such as those caused by negligent vaccine administration. Given that 
the Vaccine Act seeks to replace state tort remedies for the injuries 
it covers, this reinforces the conclusion that the Act does not reach 
SIRVA and vasovagal syncope.
    Fifth, Congress provided for health care providers who administer 
vaccines to record detailed information about the vaccination, 
including the date of administration; the manufacturer; the name of the 
provider; and other identifying information. 42 U.S.C. 300aa-25. This 
information is well suited to a program designed to compensate for 
injuries associated with the vaccine itself, since it provides the key 
details about the vaccine provided and when. But this reporting 
requirement is woefully inadequate if the Program was designed to 
compensate for negligence by the provider, which would require 
maintaining careful records regarding the actual administration of the 
vaccine.
    To be sure, the Vaccine Act does in certain places refer to 
``administration of'' or the ``administrator'' of the vaccine. But we 
think that those usages were not meant to suggest the Program covers 
negligence in the administration of the vaccine, but served other 
purposes. At most, these usages render the statute ambiguous with 
respect to needle injuries. In Section 300aa-11(a)(2)(A), the statute 
precludes suits against ``a vaccine administrator,'' but this reference 
does not define the scope of the compensation program--instead, it 
protects administrators from suits ``arising from a vaccine-related 
injury or death associated with the administration of a vaccine.'' This 
language is not entirely clear, as it appears to impose two distinct 
qualifications that both must be met but are worded slightly 
differently. It may be a belt and suspenders approach to ensure that 
vaccine administrators are protected from tort claims like in Amendola, 
where the vaccine itself was properly administered and caused the 
injury, but the petitioner alleged the administrator was negligent in 
deciding to give the vaccine. See 989 F.2d at 1186 (holding Vaccine 
Program does not exclude cases of ``negligence in deciding, for 
example, whether to administer an otherwise satisfactory vaccine''). 
The important point is that the first qualification--``arising from a 
vaccine-related injury''--is also included here and, as discussed 
above, Congress defined this requirement to include only injuries 
associated with the vaccine itself. See also 42 U.S.C. 300aa-
11(b)(1)(A) (referencing individuals who ``died as the result of the 
administration of a vaccine'' but only if the individual sustained a 
``vaccine-related injury''). In setting up the original Vaccine Injury 
Table, Congress referenced conditions ``resulting from the 
administration of such vaccines.'' 42 U.S.C. 300a-14(a). But this 
phrase was not designed to define the scope of the program or the 
Table; instead, Congress directed the Secretary to add conditions to 
the Table if they were ``associated with such vaccines.'' 42 U.S.C. 
300aa-14(e)(1)(B) & (2)(B). And it is telling that Congress included 
nothing similar to SIRVA or other injuries caused by negligent vaccine 
administration in the original Table, rather than injuries associated 
with the vaccine components themselves. Finally, that Congress asked 
the Secretary to ``make or assure improvements'' in the 
``administration'' of vaccines, 42 U.S.C. 300aa-27(a)(2), among many 
areas of improvement in the vaccination process, does not imply that 
the compensation program covers negligent administration.
    Perhaps for some or all of these reasons, state courts have found 
that injuries arising from negligent administration of a vaccine are 
not ``vaccine-related injuries'' under 42 U.S.C. 300aa-33(5), and 
therefore are not preempted by the Vaccine Act. See, e.g., Neddeau v. 
Rite Aid of Conn., 2015 WL 5133151, at *3 (Super. Ct. Conn. July 28, 
2015) (state court action did not allege a ``vaccine-related'' injury 
and therefore was not barred by the Vaccine Act, because plaintiff's 
allegation that the administrator struck the needle too high was an 
allegation that her injuries ``were caused by negligence in the 
physical process of injecting the vaccine, not by the effects of the 
vaccine''); Nwosu ex rel. Ibrahim v. Adler, 969 So. 2d 516, 519 (Ct. 
App. Fla. 2007) (claim arising from a physician's negligent injection 
of a vaccine was not a ``vaccine-related injury,'' and adding that 
``[i]t is true that had the child not been vaccinated, she would not 
have been injured. However, her injury as alleged, does not flow from 
the inoculant injected into her body [so] it is not the type of injury 
covered under the Act'').
    The Table should only include injuries caused by a vaccine or its 
components, not the manner in which the vaccine was administered. Thus, 
a petitioner must have an injury or death ``associated'' with the 
vaccine, not one resulting from poor injection technique or other 
improper administration of the vaccine.
    Moreover, strong policy considerations support this reading of the 
Vaccine Act. It is the Department's belief that Congress intended for 
the Vaccine Act's compensation system to be used for unavoidable 
injuries and illnesses that cannot be predicted in advance and can 
occur without fault. SIRVA and vasovagal syncope are generally not 
those types of injuries or illnesses. With proper injection technique, 
SIRVA is likely preventable. The scientific literature also suggests 
that those administering vaccines can take steps to significantly 
reduce the likelihood of vasovagal syncope. However, while the 
Department is grateful for the many health care professionals and 
pharmacists who improve public health by vaccinating the American 
public, and does not believe they would intentionally administer a 
vaccine in an improper manner, awarding no-fault compensation from the 
VICP to those with SIRVA and vasovagal syncope claims lessens the 
incentive to take appropriate precautions. Since Vaccine Act 
proceedings are generally sealed and not made available to the public, 
vaccine administrators may be left unaware that they used an improper 
technique.\15\ If SIRVA and vasovagal

[[Page 43798]]

syncope are included in the Table, petitioners will continue to seek to 
recover from the VICP, where they can recover more easily because they 
need not prove causation, rather than from those who failed to properly 
administer the vaccine.
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    \15\ See Jodie Fleischer et al., Half of All New Federal Vaccine 
Cases Allege Injury from Shots Given Incorrectly, NBC Washington, 
https://www.nbcwashington.com/investigations/Half-of-All-New-Federal-Vaccine-Injury-Cases-Allege-Shots-Given-Incorrectly-481441201.html (explaining that ``the program has no mechanism [due 
to privacy laws] to notify the shot-giver of the injury he or she 
likely caused,'' and ``[t]hus, they would have no reason to seek 
additional training'').
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    Furthermore, the Department has found that SIRVA petitions are 
likely to unnecessarily risk reductions in the funding available for 
children and others who sustained an unavoidable vaccine-related injury 
or death that did not result from improper technique or negligent 
administration. In the VICP's early years, the overwhelming majority of 
cases brought, and compensation awarded, involved injuries to 
children.\16\ However, over 99.2% of SIRVA cases (3,034 out of 3,057) 
filed since FY 2010 were filed by adults. From FY 2016 through FY 2019, 
approximately $119,154,985 has been paid out of the Vaccine Injury 
Compensation Trust Fund (Trust Fund) to compensate SIRVA petitioners, 
who are overwhelmingly adults. The sheer prevalence of shoulder 
injuries in the country's adult population and the low burden of proof 
placed on petitioners have made it attractive to file SIRVA petitions, 
even when such claims are dubious.\17\ Petitioners in such cases often 
prevail because of the low burden of proof and because it is not 
necessary to prove causation. If SIRVA and vasovagal syncope were 
removed from the Table, individuals could still file SIRVA and 
vasovagal syncope claims in state court \18\ where they would be 
required to prove causation between the manner of administration and 
the claimed injury. Requiring plaintiffs to prove causation in state 
court would mitigate the filing of frivolous claims in the VICP that 
are diminishing the Trust Fund.
---------------------------------------------------------------------------

    \16\ Peter H. Meyers, Fixing the Flaws in the Federal Vaccine 
Injury Compensation Program, 63 Admin. L. Rev. 785, 795 (2011).
    \17\ See also B.F. Hibbs, C.S. Ng, O. Museru et al., Reports of 
atypical shoulder pain and dysfunction following inactivated 
influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 
2010-2017, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.023 
(reports of atypical shoulder pain following IIV are uncommon and 
the level of reporting has remained fairly constant in recent years, 
``in contrast to the substantial increase in SIRVA claims filed with 
the VICP for IIV during the same time period'').
    \18\ Or Federal district court if they satisfy the requirements 
of 28 U.S.C. 1332 or 28 U.S.C. 1367.
---------------------------------------------------------------------------

    The removal of SIRVA and vasovagal syncope from the Table is 
intended to also preclude VICP claims for SIRVA or vasovagal syncope 
based on causation in fact, given that they are not injuries associated 
with vaccines or their components, nor are they unavoidable injuries or 
illnesses that cannot be predicted in advance, or that can occur 
without fault. While only eight and nine vasovagal syncope claims were 
filed in FY 18 and FY 19 respectively, the number of SIRVA claims has 
increased since the agency began suggesting that SIRVA could be a Table 
injury, and increased dramatically after SIRVA was in fact added to the 
Table in FY 17:

------------------------------------------------------------------------
                                                           Total number
                       Fiscal year                           of SIRVA
                                                           claims filed
------------------------------------------------------------------------
FY 2010.................................................               5
FY 2011.................................................              10
FY 2012.................................................              20
FY 2013.................................................              34
FY 2014.................................................             116
FY 2015.................................................             225
FY 2016.................................................             433
FY 2017.................................................             605
FY 2018.................................................             671
FY 2019.................................................             711
FY 2020.................................................             227
                                                         ---------------
  Totals................................................           3,057
------------------------------------------------------------------------

    Prior to SIRVA's addition to the Table, SIRVA claims were sometimes 
awarded due to a combination of the government resolving the claims 
without litigating them to conclusion, and public statements by the 
Department suggesting SIRVA was a cognizable injury. The proposal to 
add SIRVA to the Table was in the works for several years before the 
2015 notice of proposed rulemaking was published, and there was a great 
deal of public discussion about it at the ACCV and at the Court of 
Federal Claims' annual judicial conference. The Department has in the 
past not always contested cases alleging injuries that have been 
proposed for addition to the Table if the case as pleaded fulfilled the 
criteria for entitlement to compensation. However, for the reasons 
discussed in this notice of proposed rulemaking, including the 
Department's review of the statute and more recent scientific 
literature, the Department no longer believes such claims should be 
included on the Table or can be based on causation in fact, because 
they are not injuries associated with vaccines or their components, nor 
are they unavoidable injuries or illnesses that cannot be predicted in 
advance, or that can occur without fault.
    In addition, DOJ informs the Department that, out of 2,214 SIRVA 
claims filed since 2017, DOJ has identified 27 cases in which altered 
medical records have been filed, some of which involved changes to the 
site of vaccination. 2,214 SIRVA claims have been filed in this time 
period. Additionally, the median award for SIRVA claims is far higher 
than the damages awarded for comparable injuries in the civil tort 
system. See Memo re: Damages for Shoulder Injuries Outside of the 
Vaccine Program, Dep't of Justice (Sept. 21, 2018) (indicating the 
median award for SIRVA claims resolved by stipulation, which ostensibly 
include a litigative risk discount, is $71,355.26, but is $22,530 for 
comparable claims awarded either by settlement or judgment in the civil 
tort system in 2015-2018); see also Bossenbroek v. HHS, 2020 WL 
2510454, Appendix 2 (Fed. Cl. Spec. Mstr. Apr. 3, 2020) (citing the DOJ 
memo). The Department is concerned that the alteration of records and 
excessive awards to petitioners seen in SIRVA cases threaten the 
integrity of the VICP.
    In FY 10, SIRVA claims made up 5 (1.1%) of the 448 claims filed in 
the VICP. However, for FY17-FY19, SIRVA claims made up 52.6% of all 
claims filed in the VICP. Thus, indications that SIRVA claims were 
cognizable and then adding SIRVA to the Table dramatically increased 
the number of claims filed in the VICP. Such claims, which are not 
associated with vaccines or their components, therefore erroneously 
suggest that vaccines are less safe than they in fact are. For example, 
if no SIRVA claims were filed, the number of claims filed in FY 19 
would have fallen from 1,282 to 575. Thus, reductions in VICP 
petitions, particularly those claiming SIRVA, will support the 
overwhelming scientific understanding that vaccines are both safe and 
effective.

Item XVII

    As discussed in further detail below, the Department also proposes 
to remove Item XVII from the Table found at 42 CFR 100.3(a), and to 
remove 42 CFR 100.3(e)(8), which describes the mechanism for adding new 
vaccines to Item XVII. The Department proposes these changes because it 
has serious concerns that Item XVII is contrary to law, including the 
procedures described in the Vaccine Act for amending the Table. 
Specifically, to the extent that Item XVII provides a unilateral 
mechanism for adding injuries and vaccines to the Table, it may be 
inconsistent with the Vaccine Act, as discussed in more detail below. 
SIRVA and vasovagal syncope are the only illnesses, disabilities, 
injuries, or conditions listed for Item XVII.

[[Page 43799]]

Guiding Principles for Recommending Changes to the Vaccine Injury Table

    In 2006, the ACCV established ``Guiding Principles for Recommending 
Changes to the Vaccine Injury Table'' (Guiding Principles) to assist 
the ACCV in evaluating proposed Table revisions and determining whether 
to recommend changes to the Table to the Secretary. The Guiding 
Principles consist of two overarching principles: (1) The Table should 
be scientifically and medically credible, and (2) where there is 
credible scientific and medical evidence both to support and to reject 
a proposed change (addition or deletion) to the Table, the change 
should, whenever possible, be made to the benefit of petitioners. The 
Guiding Principles also state, among other factors, that ``[t]o the 
extent that the [IOM] has studied the possible association between a 
vaccine and an adverse effect, the conclusions of the IOM should be 
considered by the ACCV and deemed credible but those conclusions should 
not limit the deliberations of the ACCV.'' As part of its mandate under 
the Act, the ACCV considered the proposed changes set forth in this 
NPRM on March 6, 2020 and May 18, 2020.\19\ Four members of the ACCV 
also held a workgroup meeting on April 3, 2020 to discuss the proposed 
changes. For each proposed change by the Secretary, the ACCV voted for 
one of three options:
---------------------------------------------------------------------------

    \19\ The Department first provided the proposed revisions to the 
Table and requested recommendations and comments by the ACCV on or 
about February 15, 2020.
---------------------------------------------------------------------------

    1. ACCV concurs with the proposed change(s) to the Table and would 
like the Secretary to move forward (with or without comments);
    2. ACCV does not concur with the proposed change(s) to the Table 
and would not like the Secretary to move forward; or
    3. ACCV would like to defer a recommendation on the proposed 
change(s) to the Table pending further review at a future ACCV meeting.
    The Guiding Principles are not binding on the Secretary. The ACCV's 
findings and recommendations are discussed at page 26-31.
Findings
    In prior Table revisions, the Secretary determined that the 
appropriate framework for making changes to the Table is to make 
specific findings as to the illnesses or conditions that can reasonably 
be determined in some circumstances to be caused or significantly 
aggravated by the vaccines under review and the circumstances under 
which such causation or aggravation can reasonably be determined to 
occur. The Secretary continues this approach, and finds that the 
scientific literature does not provide a sufficient association between 
either SIRVA or vasovagal syncope and any vaccine component alone so as 
to support including SIRVA or vasovagal syncope in the Table. 
Accordingly, the Secretary proposes to remove SIRVA and vasovagal 
syncope from the Table and from the QAI found at 42 CFR 100.3(c) for 
the reasons discussed in this NPRM. The Secretary also has serious 
concerns that Item XVII does not comport with applicable law, and 
therefore also recommends removal of Item XVII from the Table and the 
removal of 42 CFR 100.3(e)(8) for the reasons discussed in this NPRM. 
For any vaccine adverse event pairs for which future scientific 
evidence develops to support a finding of a causal relationship, the 
Secretary will consider future rulemaking to revise the Table 
accordingly.
    In support of his proposals, and notwithstanding the 
recommendations of the ACCV, the Secretary makes the following 
findings:
Findings That Result in Removals From the Table Because the Evidence 
Favors Rejection of a Causal Relationship
    1. The scientific evidence does not adequately support a causal 
relationship between any specific vaccine's antigen or other component 
and SIRVA. For reasons detailed below, the Secretary proposes removing 
SIRVA from the Table.
    2. The scientific evidence does not adequately support a causal 
relationship between any specific vaccine's antigen or other components 
and vasovagal syncope. For reasons detailed below, the Secretary 
proposes removing vasovagal syncope from the Table.
Findings That Result in Removals From the Table for Procedural Reasons
    1. Item XVII in the Table may not comport with applicable law. For 
reasons detailed below, the Secretary proposes removing Item XVII from 
the Table.

III. Discussion of Proposed Rule

    The Secretary has examined the relevant statutory provisions, the 
scientific literature, the Department's experience since SIRVA and 
vasovagal syncope were added to the Table, and the recommendations of 
the ACCV and proposes that the Table set forth at 42 CFR 100.3(a) be 
revised to remove SIRVA, vasovagal syncope, and Item XVII, as described 
below. Due to these amendments, the Secretary also proposes making the 
corresponding changes of removing 42 CFR 100.3(c)(10), 42 CFR 
100.3(c)(13), and 42 CFR 100.3(e)(8), which describe the injuries or 
items that the Secretary proposes to remove from the Table. Following 
each proposed removal from the Table, as applicable, there is a 
discussion of the 2017 addition of each injury to the Table, the IOM's 
2012 conclusions about that injury cited by HHS in its 2015 Proposed 
Rule, and other relevant research and conclusions, as well as the 
Department's proposal. Each of the changes proposed by the Department 
and the rationale for the proposal is described in detail.
    As provided in 42 U.S.C. 300aa-14(c)(4), the modified Table will 
apply only to petitions filed under the Program after the effective 
date of the final regulation. Petitions must also be filed within the 
applicable statute of limitations. The general statute of limitations 
applicable to petitions filed with the VICP, set forth in 42 U.S.C. 
300aa-16(a), continues to apply. In addition, the statute identifies a 
specific exception to this statute of limitations that applies when the 
effect of a revision to the Table makes a previously ineligible person 
eligible to receive compensation or when an eligible person's 
likelihood of obtaining compensation significantly increases.
    Under 42 U.S.C. 300aa-16(b), an individual who may be eligible to 
file a petition based on the revised Table may file the petition for 
compensation not later than 2 years after the effective date of the 
revision if the injury or death occurred not more than 8 years before 
the effective date of the revision of the Table. This is true even if 
such individual previously filed a petition for compensation, and is 
thus an exception to the ``one petition per injury'' limitation of 42 
U.S.C. 300aa-11(b)(2).
    Based on the requirements of the Administrative Procedure Act, the 
Department publishes a Notice of Proposed Rulemaking in the Federal 
Register before a regulation is promulgated. The public is invited to 
submit comments on the proposed rule. In addition, a public hearing 
will be held for this proposed rule.
    After the public comment period has expired, the comments received 
and the Department's responses to the comments will be addressed in the 
preamble to the final regulation. The Department will publish the final 
rule in the Federal Register.
    In the following sections, background information on different 
injuries and Item XVII, as well as the Secretary's rationale for the 
proposed Table changes, is provided.

[[Page 43800]]

1. Shoulder Injury Related to Vaccination
    SIRVA is an adverse event following vaccination thought to be 
related to the technique of intramuscular percutaneous injection (the 
procedure where access to a muscle is obtained by using a needle to 
puncture the skin) into an arm resulting in trauma from the needle and/
or the unintentional injection of a vaccine into tissues and structures 
lying underneath the deltoid muscle of the shoulder.
    On March 21, 2017, HHS adopted the Final Rule adding SIRVA to the 
Table. As defined in the Final Rule, SIRVA is an injury related to the 
intramuscular injection of a vaccine. Since the addition of SIRVA to 
the Table, SIRVA has become the predominant claim under the National 
Vaccine Injury Compensation Program. In Fiscal Year 2018, of the 1,238 
claims filed, 671 were SIRVA claims (54.2%). In Fiscal Year 2019, of 
the 1,282 claims filed, 711 were SIRVA claims (55.4%). Thus, the number 
of SIRVA claims have increased dramatically, having comprised only 5 
(1.1%) of the 448 claims filed in Fiscal Year 2010 and 10 (2.6%) of the 
386 claims filed in Fiscal Year 2011.
    By definition, a Table injury of SIRVA results from the injection 
technique. For that reason, the Department did not include SIRVA as an 
injury on the 2017 revised Table for vaccines that are not administered 
by intramuscular injection, including oral polio and rotavirus; 
subcutaneous MMR, MMRV, varicella, and meningococcal-polysaccharide; 
and intranasal influenza. In addition, the Department did not add a 
SIRVA injury to the revised 2017 Table for vaccines administered via a 
needleless jet device. Similarly, the Department found that a SIRVA 
injury would not apply to formulations of influenza vaccine where the 
route of administration was intradermal, such as those delivered 
through a needle that was only 1.5 millimeters long, because the 
``needle is not long enough to enter the deltoid bursa or any other 
structure in the shoulder related to the development of SIRVA.'' \20\
---------------------------------------------------------------------------

    \20\ 80 FR 45144.
---------------------------------------------------------------------------

    In addition, in the 2012 IOM review of medical and scientific 
literature related to SIRVA cited by the Department in the 2015 
Proposed Rule, the IOM found a causal connection between the injury of 
deltoid bursitis and vaccine injection with a needle only.\21\ The IOM 
did not find a causal connection between the injury of deltoid bursitis 
and the components of the vaccine itself.
---------------------------------------------------------------------------

    \21\ 80 FR 45136. See also IOM Report.
---------------------------------------------------------------------------

    Since the final rule was promulgated, additional scientific 
research has concluded that subdeltoid or subacromial bursitis and 
other shoulder lesions are ``more likely to be the consequence of a 
poor injection technique (site, angle, needle size, and failure to take 
into account patient's characteristics, i.e., sex, body weight, and 
physical constitution),'' rather than ``antigens or adjuvants contained 
in the vaccines that would trigger an immune or inflammatory 
response.'' \22\ The evidence is thus insufficient to support an 
adequate causal connection between the contents of any vaccine by 
themselves and SIRVA.
---------------------------------------------------------------------------

    \22\ Mart[iacute]n Arias, K.H., Fadrique, R., S[aacute]inz Gil, 
M., and Salgueiro-Vazquez, M.E., Risk of bursitis and other injuries 
and dysfunctions of the shoulder following vaccinations, Vaccine, 
2017 35:4870-4876; Bancsi A, Houle SKD, Grindrod KA. Shoulder injury 
related to vaccine administration and other injection site events. 
Can. Fam. Physician. 2019 Jan; 65(1):40-42 (explaining that SIRVA 
``is a preventable occurrence caused by the injection of a vaccine 
into the shoulder capsule rather than the deltoid muscle''); Macomb 
CV, Evans MO, Dockstater JE, Montgomery JR, Beakes DE. Treating 
SIRVA Early With Corticosteroid Injections: A Case Series. Mil Med. 
2019 Oct 17 (noting that SIRVA does not occur unless the vaccine is 
mistakenly given in the shoulder capsule).
---------------------------------------------------------------------------

    As discussed above, it is the Department's belief that SIRVA is not 
a ``vaccine-related injury'' and therefore should not be included on 
the Table or compensable under the VICP.\23\ Moreover, as discussed in 
the Background section, the Department has concluded that there are 
strong policy reasons for removing SIRVA from the Table. Accordingly, 
the Secretary recommends removing SIRVA altogether from the Table.
---------------------------------------------------------------------------

    \23\ 42 U.S.C. 300aa-11, 300aa-14(e).
---------------------------------------------------------------------------

2. Vasovagal Syncope
    Vasovagal syncope is the loss of consciousness (fainting) caused by 
a transient decrease in blood flow to the brain. Vasovagal syncope is 
usually a benign condition but may result in falling and injury.
    On January 19, 2017, the Department adopted the Final Rule adding 
vasovagal syncope to the Table. 82 FR 6294; 82 FR 11321. In making that 
revision, the Department relied on the IOM's 2012 review of medical and 
scientific literature concerning a possible link between the injection 
of a vaccine and syncope. The IOM found insufficient epidemiologic 
evidence of an association between the injection of a vaccine and 
syncope, but it found sufficient mechanistic evidence supporting the 
conclusion that syncope is ``directly related to vaccine 
administration.'' \24\ The IOM explained that evidence it examined as 
part of its review suggested ``that the injection, and not the contents 
of the vaccine, contributed to the development of syncope.'' \25\ In 
addition, because syncope is an injury related solely to the injection 
of a vaccine, the Department did not add syncope to the 2017 revisions 
to the Table as an injury for vaccines that are not administered by 
injection, such as oral polio and rotavirus vaccine.
---------------------------------------------------------------------------

    \24\ 80 FR 45137.
    \25\ 80 FR 45137. See also IOM Report.
---------------------------------------------------------------------------

    Other scientific and medical literature support the conclusion that 
syncope may be caused by the act of vaccination, but not its 
contents.\26\ The evidence is thus insufficient to support a causal 
connection between the contents of any vaccine and vasovagal syncope.
---------------------------------------------------------------------------

    \26\ 80 FR 45137 (The IOM found that one case report suggested 
that ``the injection, and not the contents of the vaccine, 
contributed to the development of syncope''). See also IOM Report at 
18 (``injection of vaccine, independent of the antigen involved, can 
lead to'' syncope); Miller, E. and Woo, E.J. Time to prevent 
injuries from postimmunization syncope, Nursing, 2006 36 (12): 20.
---------------------------------------------------------------------------

    As discussed above, it is the Department's belief that vasovagal 
syncope is not a ``vaccine-related injury'' and therefore should not be 
included on the Table or compensable under the VICP.\27\ Moreover, as 
discussed in the Background section, the Department has concluded that 
there are strong policy reasons for removing vasovagal syncope from the 
Table. Accordingly, the Secretary recommends removing vasovagal syncope 
from the Table.
---------------------------------------------------------------------------

    \27\ 42 U.S.C. 300aa-11, 300aa-14(e).
---------------------------------------------------------------------------

3. Category for Any New Vaccine Recommended by the Centers for Disease 
Control and Prevention for Routine Administration to Children After 
Publication by the Secretary of a Notice of Coverage
    Item XVII of the current Table includes ``[a]ny new vaccine 
recommended by the CDC for routine administration to children, after 
publication by the Secretary of a notice of coverage.'' \28\ Through 
this general category, new vaccines recommended by the CDC for routine 
administration to children and subject to an excise tax are deemed 
covered under the VICP prior to being added to the Table as a separate 
vaccine category through Federal rulemaking. SIRVA and vasovagal 
syncope are the only illnesses, disabilities, injuries, or conditions 
listed in Item XVII of the Table.
---------------------------------------------------------------------------

    \28\ 42 CFR 100.3(a).

---------------------------------------------------------------------------

[[Page 43801]]

    The Department has serious concerns that Item XVII is contrary to 
law. The Vaccine Act provides a method for adding new vaccines to the 
Table, and it is far from clear that the approach in Item XVII complies 
with that method. The Vaccine Act provides that the Secretary may 
promulgate regulations to modify the Table, but in doing so, he ``shall 
provide for notice and opportunity for a public hearing and at least 
180 days of public comment.'' \29\ Moreover, the Table cannot be 
revised unless ``the Secretary has first provided to the [ACCV] a copy 
of the proposed regulation or revision, requested recommendations and 
comments by the [ACCV], and afforded the [ACCV] at least 90 days to 
make such recommendations.'' \30\ Item XVII, by contrast, suggests that 
vaccines are added to the Table once the CDC recommends them for 
routine administration to children and an excise tax is imposed, even 
prior to notice and public comment or comments from the ACCV.\31\ This 
may be inconsistent with the rulemaking requirements of the 
Administrative Procedure Act 5 U.S.C. 553, the Regulatory Flexibility 
Act, 5 U.S.C. 601 et seq., various Executive Orders that cabin 
rulemaking (see, e.g., Executive Order 12866), and the Vaccine Act.
---------------------------------------------------------------------------

    \29\ 42 U.S.C. 300aa-14(c)(1).
    \30\ 42 U.S.C. 300aa-14(d).
    \31\ The language in Item XVII also raises Constitutional 
concerns. Item XVII in effect allows CDC to add vaccines to the 
Table so long as the Secretary publishes notice of coverage. The 
Office of Legal Counsel has previously opined that a statute that 
sought to authorize the CDC director to take certain action 
unilaterally was inconsistent with the Executive Powers Clause. 
(Statute Limiting The President's Authority To Supervise The 
Director Of The Centers For Disease Control In The Distribution Of 
An AIDS Pamphlet, 12 U.S. Op. Off. Legal Counsel 47, 48, 1988 WL 
390999, at * 1). For the same reasons, it is not clear that the CDC 
director, as an inferior officer, has the authority to unilaterally 
add vaccines to the Table without the approval of the Secretary.
---------------------------------------------------------------------------

    Further, SIRVA and vasovagal syncope are the only illnesses, 
disabilities, injuries, or conditions listed for Item XVII.
4. The ACCV's Recommendations and Comments
    More than 90 days after it received the Department's proposed 
changes to the Table, on May 20, 2020 the ACCV sent a letter to the 
Secretary (May 20 Letter) explaining why it opposed the proposed 
changes.\32\ The Department is grateful to the ACCV for its time spent 
considering the proposed changes and for providing its comments.
---------------------------------------------------------------------------

    \32\ https://www.hrsa.gov/advisory-committees/vaccines/reports-recommendations.html.
---------------------------------------------------------------------------

    However, the Department found the ACCV's comments not adequately 
persuasive, and for the reasons stated above has decided to issue this 
notice of proposed rulemaking and provide for public comment and notice 
and opportunity for a public hearing. The May 20 Letter stated that, 
although rare, SIRVA and vasovagal syncope are injuries that can be 
caused by vaccination, so they should be eligible for compensation from 
the VICP. However, for the reasons stated herein, only ``vaccine-
related injuries or deaths,'' as defined in the statute, are eligible 
for compensation. The May 20 Letter also stated that one intent of the 
VICP is to provide liability protection to vaccine manufacturers and 
administrators, and that removing SIRVA or vasovagal syncope could (1) 
result in higher malpractice premiums for those who administer vaccines 
and (2) disincentivize administering vaccines, thereby resulting in 
lower vaccination rates. However, the May 20 Letter failed to cite any 
evidence that these issues were problematic in the United States before 
SIRVA and vasovagal syncope were added to the Table in 2017, and the 
Department has been unable to locate any evidence that premiums have 
materially declined due to the addition of SIRVA and vasovagal syncope 
to the Table. Moreover, the vaccination rate has gone down slightly 
since SIRVA and vasovagal syncope were added to the Table.\33\ The 
Department is grateful for the many health care professionals and 
pharmacists who improve public health by vaccinating the American 
public, and does not believe they would intentionally administer a 
vaccine in an improper manner, but the Department also wants to 
incentivize those who administer vaccines to do so properly. Doing so 
will improve public confidence in vaccinations.
---------------------------------------------------------------------------

    \33\ See, e.g., https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm; https://www.cdc.gov/nchs/data/hus/2018/031.pdf.
---------------------------------------------------------------------------

    The May 20 Letter also stated that the Vaccine Act has a 
subrogation clause which permits the Federal government to seek 
recompense if the VICP compensates a claim, but determines later that a 
health care professional was negligent in administering a vaccine. 
Thus, injury claims resulting from the administration of vaccines 
should still be eligible for VICP compensation. However, this 
subrogation provision does not properly incentivize the vaccine 
administrator, since it is unlikely that the Federal government would 
assert many claims against administrators, given the burden and expense 
compared to the relatively small potential recovery for the Federal 
government. Individuals would have a greater incentive to assert such 
claims if the administrator were negligent.
    The May 2020 Letter further stated that the explanations in the 
proposal that the Department submitted to the ACCV do not meet the 
tenets of the ACCV's Guiding Principles. As noted above, the Guiding 
Principles state: ``When recommending changes to the Vaccine Injury 
Table (``the Table''), members of the Advisory Commission on Childhood 
Vaccines (ACCV) shall utilize the following overarching guiding 
principles:

     The Table should be scientifically and medically credible; 
and
     Where there is credible scientific and medical evidence 
both to support and to reject a proposed change (addition or deletion) 
to the Table, the change should, whenever possible, be made to the 
benefit of petitioners.''
    The Guiding Principles are not binding on the Secretary.\34\ 
Nonetheless, the Department believes that credible scientific and 
medical evidence supports removing SIRVA and vasovagal syncope from the 
Table. In addition, the Secretary must consider what will benefit the 
public, not only petitioners. Furthermore, in determining whether a 
proposed change benefits petitioners, it is important to consider all 
petitioners. The inclusion of SIRVA has harmed the petitioners with 
injuries that the VICP was primarily designed to compensate, including 
children, because the high number of SIRVA claims has significantly 
slowed down the adjudication process. The Vaccine Act established a 
compensation program that was ``designed to work faster and with 
greater ease than the civil tort system.'' Bruesewitz v. Wyeth, 562 
U.S. 223, 228 (2011) (quoting Shalala v. Whitecotton, 514 U.S. 268, 
269, (1995)). However, since 2017, the average amount of time for a 
case to finally resolve has increased significantly (from 575 days to 
751 days). As of March 2020, 926 petitions awaited initial review, 
including 530 that had been filed in FY 2019.\35\ Prior to FY 2014, 
there generally were not even 530 total petitions filed per year. Non-
SIRVA cases, including those filed on behalf of children, are adversely 
affected as resources are stretched or diverted to litigate SIRVA 
cases. Because SIRVA claims are lucrative to pursue and simpler to 
prosecute than childhood vaccine injuries, there is little reason to

[[Page 43802]]

believe this is a temporary phenomenon.
---------------------------------------------------------------------------

    \34\ 80 FR 45134.
    \35\ https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/vaccines/meetings/2020/03062020-dicp-update.pdf.
---------------------------------------------------------------------------

    The May 20 Letter also stated that since enactment of the Vaccine 
Act and the inception of the program, claims resulting from the 
administration of a vaccine have been filed and some have been 
compensated. The May 20 Letter added that the ACCV was not presented 
with any new peer-reviewed medical or scientific literature on SIRVA or 
syncope. Thus, since no new medical and scientific literature has been 
published about the proposed changes, HHS should not be proposing any 
changes to the Table. However, the proposal that the Department 
provided to the ACCV, as well as this notice of proposed rulemaking, 
includes the findings of additional studies concluded since SIRVA and 
vasovagal syncope were added to the Table. The Department has also 
learned from its experience since SIRVA and vasovagal syncope were 
added to the Table, and believes this experience supports the proposed 
changes. Additionally, the Department believes the changes are 
supported by the IOM, which found that (1) ``the injection, and not the 
contents of the vaccine, contributed to the development of deltoid 
bursitis'' \36\ and (2) ``the injection, and not the contents of the 
vaccine, contributed to the development of syncope.'' \37\ Thus, there 
was insufficient scientific evidence to support adding SIRVA and 
vasovagal syncope in the first place, as there was insufficient 
evidence that either are vaccine-related injuries.
---------------------------------------------------------------------------

    \36\ IOM Report at 620.
    \37\ 80 FR 45137. See also IOM Report.
---------------------------------------------------------------------------

    The May 20 Letter added that the Trust Fund has a balance of over 
$4 billion, so funds are available to pay valid claims resulting from 
the administration of vaccines. However, it is the Department's belief 
that the availability of funds at this moment does not justify their 
dispersal for claims that are not associated with vaccines or vaccine 
components. Lastly, the May 20 Letter also recommended that the 
Secretary support an increase in the number of Special Masters and 
staffing and funding resources for the VICP in order to reduce the 
backlog caused by SIRVA claims. It is Congress's decision whether to 
increase funding and the number of Special Masters. Moreover, any 
increase in staffing or funding by Congress would only address one of 
the several issues identified above.
    The May 20 Letter did not provide any reasons why it opposed the 
Department's proposal to remove Item XVII from the Table.\38\
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    \38\ The May 20 Letter also stated that the ACCV wished it could 
have heard from an HHS official who could provide the evidence and 
reasoning to support the proposal and to explain and discuss the 
original basis for the inclusion of SIRVA and vasovagal syncope on 
the Table. While perhaps an understandable concern, the proposal, 
which synthesized the views of many within the Department, was the 
Department's best explanation for why it was proposing the changes 
to the Table.
---------------------------------------------------------------------------

    One member of the ACCV sent a letter to the Secretary on May 26, 
2020. The letter stated that the member was concerned that the large 
number of SIRVA claims has clogged the VICP, resulting in delayed 
resolution of claims; the large amount paid annually from the Trust 
Fund has reinforced vaccine hesitancy among some who incorrectly 
believe this figure reflects lack of vaccine safety; and the number of 
awards for SIRVA are in excess of the true number of cases. This member 
recommended revising the definition of SIRVA so that those with true 
shoulder injuries are able to recover while reducing the number of 
``inappropriate claims.'' The Department believes the concerns 
expressed in this letter can best be accomplished by removing SIRVA 
from the Table. If SIRVA is removed from the Table, those with SIRVA 
injuries would still be able to recover in state court. Removal is 
preferable to redefining SIRVA, because it better addresses the vaccine 
hesitancy concern, is more in line with the Vaccine Act and 
Congressional intent, and incentivizes learning proper administration 
technique. Indeed, because Vaccine Act proceedings are generally sealed 
and not made available to the public, vaccine administrators often are 
left unaware that they used an improper technique.

IV. Statutory Authority

    The primary statutory authority for this rulemaking is 42 U.S.C. 
300aa-14. 42 U.S.C. 300aa-14(c)(1) provides that the ``Secretary may 
promulgate regulations to modify in accordance with paragraph (3) the 
Vaccine Injury Table. In promulgating such regulations, he shall 
provide for notice and opportunity for a public hearing and at least 
180 days of public comment.'' 42 U.S.C. 300aa-14(c)(3), in turn, 
provides: ``A modification of the Vaccine Injury Table under paragraph 
(1) may add to, or delete from, the list of injuries, disabilities, 
illnesses, conditions, and deaths for which compensation may be 
provided or may change the time periods for the first symptom or 
manifestation of the onset or the significant aggravation of any such 
injury, disability, illness, condition, or death.''

V. Request for Comment

    HHS and HRSA request comment on all aspects of this proposed rule, 
including its likely costs and benefits and the impacts that it is 
likely to have on the public health, as compared to the current 
requirements under 42 CFR 100.3.

VI. Statutory and Regulatory Requirements

A. Executive Orders 12866, 13563, and 13771: Regulatory Planning and 
Review

    E.O. 12866 and E.O. 13563 direct agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). E.O. 13563 supplements and 
reaffirms the principles, structures, and definitions governing 
regulatory review as established in E.O. 12866, which emphasizes the 
importance of quantifying both costs and benefits, of reducing costs, 
of harmonizing rules, and of promoting flexibility.
    Executive Order 12866 requires that all regulations reflect 
consideration of alternatives, of costs, of benefits, of incentives, of 
equity, and of available information. Regulations must meet certain 
standards, such as avoiding an unnecessary burden. Regulations that are 
``significant'' because of cost, adverse effects on the economy, 
inconsistency with other agency actions, effects on the budget, or 
novel legal or policy issues require special analysis. The Department 
anticipates that the proposed rule would save limited compensation 
funds under the National Vaccine Injury Compensation Program. 
Specifically, it will reduce the amount of program funds spent on 
program administration, reduce the amount of funds paid out to those 
with SIRVA or vasovagal syncope claims, and ensure that funds awarded 
from the VICP are awarded to individuals whose claims arise from 
vaccine-related injuries, which is consistent with the original intent 
of the VICP. Moreover, the Department anticipates that the proposed 
rule may result in fewer individuals suffering from SIRVA or vasovagal 
syncope, because it will better incentivize those administering 
vaccines to use proper injection technique. If those who administer 
vaccines can be held liable when a patient suffers from SIRVA or 
vasovagal syncope as a result of the administration

[[Page 43803]]

of the vaccine, those who administer vaccines will have greater 
incentive to use proper injection technique. In addition, the proposed 
rule may also limit the ability of those opposed to vaccinations to 
cite to the high number of SIRVA awards to misleadingly suggest that 
vaccines are less safe than they truly are.
    The Department considered, as an alternative to this NPRM, issuing 
a NPRM that would revise the definition of SIRVA so that those with 
true shoulder injuries were able to recover while reducing the number 
of less appropriate claims. However, the Department concluded that 
removing SIRVA from the Table is preferable. If SIRVA is removed from 
the Table, those with actual SIRVA injuries would still be able to 
recover in state court. Removal is preferable to redefining SIRVA, 
because it better addresses the vaccine hesitancy concern, is more in 
line with the Vaccine Act and Congressional intent, and incentivizes 
learning and utilizing proper administration technique. Indeed, because 
Vaccine Act proceedings are generally sealed and not made available to 
the public, vaccine administrators often are left unaware that they 
used an improper technique.
    The Department also considered, as alternatives to this NPRM, not 
removing one or more of (1) SIRVA, (2) vasovagal syncope, or (3) Item 
XVII from the Table. For the reasons discussed herein, the Department 
rejected these alternatives.
    Section 3(f) of Executive Order 12866 defines a ``significant 
regulatory action'' as an action that is likely to result in a rule (1) 
having an annual effect on the economy of $100 million or more in any 
one year, or adversely or materially affecting a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or state, local or tribal governments or communities (also 
referred to as ``economically significant''); (2) creating a serious 
inconsistency or otherwise interfering with an action taken or planned 
by another agency; (3) materially altering the budgetary impacts of 
entitlement grants, user fees, or loan programs or the rights and 
obligations of recipients thereof; or (4) raising novel legal or policy 
issues arising out of legal mandates, the President's priorities, or 
the principles set forth in the Executive Order. A regulatory impact 
analysis bust be prepared for major rules with economically significant 
effects ($100 million or more in any one year), and a ``significant'' 
regulatory action is subject to Office of Management and Budget (OMB) 
review. As discussed below regarding the anticipated effects, these 
proposals are not likely to have economic impacts of $100 million or 
more in any one year, and therefore do not meet the definition of 
``economically significant'' under Executive Order 12866. OMB has 
determined, however, that the actions are significant within the 
meaning of section 3(f)(4) of the Executive Order. Accordingly, this 
rule has been reviewed by OMB.

B. Economic and Regulatory Impact

    In accordance with the Regulatory Flexibility Act of 1980 (RFA), 
and the Small Business Regulatory Enforcement Act of 1996, which 
amended the RFA, the Secretary certifies that this rule will not have a 
significant impact on a substantial number of small entities. Between 
FY 2017 and FY 2019, the VICP on average paid out $30,893,481.90 per 
year to petitioners alleging SIRVA claims. The VICP on average paid out 
$124,489.56 per year to petitioners alleging vasovagal syncope claims. 
If this proposed rule went into effect, the Department anticipates that 
small entities would not actually pay these amounts, because fewer 
SIRVA and vasovagal syncope claims would be filed if petitioners had to 
prove causation. In addition, vaccines are often administered by non-
small entities, so even if total amounts paid approximated the amounts 
paid on average between FY 2017 and FY 2019, claims against small 
entities would be less. Should this rule be finalized as proposed, it 
is the Department's belief that should the amounts paid equal the 
amounts annually paid out of the VICP between FY 2017 and FY 2019, and 
such claims were paid in full by small entities, these amounts would 
not constitute a significant impact on a substantial number of small 
entities for purposes of the RFA.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Unfunded 
Mandates Act) (2 U.S.C. 1532) requires that covered agencies prepare a 
budgetary impact statement before promulgating a rule that includes any 
Federal mandate that may result in the expenditure by State, local, and 
tribal governments, in the aggregate, or by the private sector, of $100 
million in 1995 dollars, updated annually for inflation. Currently, 
that threshold is approximately $154 million. If a budgetary impact 
statement is required, section 205 of the Unfunded Mandates Act also 
requires covered agencies to identify and consider a reasonable number 
of regulatory alternatives before promulgating a rule. The Department 
has determined that this proposed rule will not result in expenditures 
by State, local, and tribal governments, or by the private sector, of 
$154 million or more in any one year. Accordingly, the Department has 
not prepared a budgetary impact statement or specifically addressed the 
regulatory alternatives considered.
    The provisions of this rule will also not negatively affect family 
well-being or the following family elements: Family safety; family 
stability; marital commitment; parental rights in the education, 
nurture and supervision of their children; family functioning; 
disposable income or poverty; or the behavior and personal 
responsibility of youth, as determined under section 654(c) of the 
Treasury and General Government Appropriations Act of 1999.
    On January 30, 2017, the White House issued Executive Order 13771 
on Reducing Regulation and Controlling Regulatory Costs. Section 2(a) 
of Executive Order 13771 requires an agency, unless prohibited by law, 
to identify at least two existing regulations to be repealed when the 
agency publicly proposes for notice and comment or otherwise 
promulgates a new regulation. In furtherance of this requirement, 
section 2(c) of Executive Order 13771 requires that the new incremental 
costs associated with new regulations shall, to the extent permitted by 
law, be offset by the elimination of existing costs associated with at 
least two prior regulations. This proposed rule would partially repeal 
prior regulations and is not expected to increase incremental costs, so 
it is not anticipated to be a regulatory or deregulatory action under 
Executive Order 13771. Public comments will inform the ultimate 
designation of this rule.
    As stated above, this proposed rule would modify the Vaccine Injury 
Table to ensure that the Table complies with applicable law, the Table 
is consistent with medical and scientific literature, those 
administering vaccines have additional incentive to use proper 
injection technique, and the VICP has sufficient funds to adequately 
compensate those injured by vaccines listed in the Table.
Summary of Impacts
    This proposed rule will have the effect of removing injuries from 
the Table that are not encompassed by the provisions of the Vaccine Act 
and that are reducing the pool of funds available to those injured by 
vaccines or vaccine components. It will therefore align the Table with 
the Department's understanding of Congress' intent and

[[Page 43804]]

public policy in favor of compensating those harmed by injuries 
associated with the vaccine or vaccine components, and particularly 
children who have suffered such harm. The rule will also have the 
effect of ensuring that the limited compensation resources available 
under the National Vaccine Injury Compensation Program are provided to 
those with vaccine-related injuries or deaths. In addition, because of 
the large volume of SIRVA claims, removing SIRVA from the Table will 
reduce the amount of program funds spent on program administration and 
ensure that funds awarded from the VICP are awarded to individuals 
whose claims arise from vaccine-related injuries, which is consistent 
with the Department's interpretation of the original intent of the 
VICP.
    The rule will also better incentivize those who administer vaccines 
to use proper injection technique. It may also help correct misleading 
and erroneous suggestions that vaccines are not safe. Because COVID-19 
and a potential COVID-19 vaccine are not currently on the Table, the 
Department does not believe this rule would have an impact on patients 
with COVID-19 or a COVID-19 vaccine. However, HHS requests public 
comment on this determination.
    Moreover, the rule is unlikely to unduly burden the civil tort 
system. The Department conducted a search in the WestLaw legal database 
for cases in state court that contained both the terms ``SIRVA'' and 
``vaccine,'' and found only 20 hits, at least two of which were cases 
involving an entity named SIRVA and not the injury.\39\ It is possible 
that some additional cases were filed in federal district court. 
Nonetheless, the Department believes based on this data that any 
additional burden on the civil tort system, which would be dispersed 
across States and not concentrated in any one or few States, from 
removing SIRVA and vasovagal syncope from the Table and reverting to 
the status quo as of January 2017 will be minimal.
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    \39\ https://1.next.westlaw.com/Search/Results.html?query=%22sirva%22%20%26%20%22vaccine%22&jurisdiction=ALLSTATES&saveJuris=False&contentType=CASE&querySubmissionGuid=i0ad6ad3f000001733a44933a7bf4372d&startIndex=1&searchId=i0ad6ad3f000001733a44933a7bf4372d&kmSearchIdRequested=False&simpleSearch=False&isAdvancedSearchTemplatePage=False&skipSpellCheck=False&isTrDiscoverSearch=False&thesaurusSearch=False&thesaurusTermsApplied=False&ancillaryChargesAccepted=False&proviewEligible=False&eventingTypeOfSearch=FRM&transitionType=Search&contextData=%28sc.Search%29.
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A. Executive Order 13132--Federalism

    HHS has reviewed this proposed rule in accordance with E.O. 13132 
regarding federalism and has determined that it does not have 
``federalism implications.'' This proposed rule would not ``have 
substantial direct effects on the States, or on the relationship 
between the national government and the States, or on the distribution 
of power and responsibilities among the various levels of government.''

B. Collection of Information

    The Paperwork Reduction Act of 1995 (44 U.S.C. 3507(d)) (PRA) 
requires that OMB approve all collections of information by a federal 
agency from the public before they can be implemented. This proposed 
rule is projected to have no impact on current reporting and 
recordkeeping burden, as the amendments proposed in this rule will not 
impose any data collection requirements under the PRA.

List of Subjects in 42 CFR Part 100

    Biologics, Health insurance, Immunization.

    Dated: June 22, 2020.
Thomas J. Engels,
Administrator, Health Resources and Services Administration.
    Approved: July 9, 2020.
Alex M. Azar II,
Secretary, Department of Health and Human Services.

    Accordingly, 42 CFR part 100 is proposed to be amended as set forth 
below:

PART 100--VACCINE INJURY COMPENSATION

0
1. The authority citation for 42 CFR part 100 continues to read as 
follows:

    Authority:  Secs. 312 and 313 of Public Law 99-660 (42 U.S.C. 
300aa-1 note); 42 U.S.C. 300aa-10 to 300aa-34; 26 U.S.C. 4132(a); 
and sec. 13632(a)(3) of Public Law 103-66.

0
2. In Sec.  100.3, revise paragraph (a) and remove paragraphs (c)(10) 
and (13) and (e)(8).
    The revision reads as follows:


Sec.  100.3   Vaccine injury table.

    (a) In accordance with section 312(b) of the National Childhood 
Vaccine Injury Act of 1986, title III of Public Law 99-660, 100 Stat. 
3779 (42 U.S.C. 300aa-1 note) and section 2114(c) of the Public Health 
Service Act, as amended (PHS Act) (42 U.S.C. 300aa-14(c)), the 
following is a table of vaccines, the injuries, disabilities, 
illnesses, conditions, and deaths resulting from the administration of 
such vaccines, and the time period in which the first symptom or 
manifestation of onset or of the significant aggravation of such 
injuries, disabilities, illnesses, conditions, and deaths is to occur 
after vaccine administration for purposes of receiving compensation 
under the Program. Paragraph (b) of this section sets forth additional 
provisions that are not separately listed in this Table but that 
constitute part of it. Paragraph (c) of this section sets forth the 
Qualifications and Aids to Interpretation for the terms used in the 
Table. Conditions and injuries that do not meet the terms of the 
Qualifications and Aids to Interpretation are not within the Table. 
Paragraph (d) of this section sets forth a glossary of terms used in 
paragraph (c).

            Table 1 to Sec.   100.3(a)--Vaccine Injury Table
------------------------------------------------------------------------
                                                       Time period for
                                                      first symptom or
                                                      manifestation of
                              Illness, disability,       onset or of
           Vaccine             injury or condition       significant
                                     covered          aggravation after
                                                           vaccine
                                                       administration
------------------------------------------------------------------------
I. Vaccines containing        A. Anaphylaxis......  <=4 hours.
 tetanus toxoid (e.g., DTaP,  B. Brachial Neuritis  2-28 days (not less
 DTP, DT, Td, or TT).                                than 2 days and not
                                                     more than 28 days).
II. Vaccines containing       A. Anaphylaxis......  <=4 hours.
 whole cell pertussis         B. Encephalopathy or  <=72 hours.
 bacteria, extracted or        encephalitis.
 partial cell pertussis
 bacteria, or specific
 pertussis antigen(s) (e.g.,
 DTP, DTaP, P, DTP-Hib).
III. Vaccines containing      A. Anaphylaxis......  <=4 hours.
 measles, mumps, and rubella  B. Encephalopathy or  5-15 days (not less
 virus or any of its           encephalitis.         than 5 days and not
 components (e.g., MMR, MM,                          more than 15 days).
 MMRV).

[[Page 43805]]

 
IV. Vaccines containing       A. Chronic arthritis  7-42 days (not less
 rubella virus (e.g., MMR,                           than 7 days and not
 MMRV).                                              more than 42 days).
V. Vaccines containing        A. Thrombocytopenic   7-30 days (not less
 measles virus (e.g., MMR,     purpura.              than 7 days and not
 MM, MMRV).                                          more than 30 days).
                              B. Vaccine-Strain
                               Measles Viral
                               Disease in an
                               immunodeficient
                               recipient.
                              --Vaccine-strain      Not applicable.
                               virus identified.
                              --If strain           <=12 months.
                               determination is
                               not done or if
                               laboratory testing
                               is inconclusive.
VI. Vaccines containing       A. Paralytic Polio..
 polio live virus (OPV).
                              --in a non-           <=30 days.
                               immunodeficient
                               recipient.
                              --in an               <=6 months.
                               immunodeficient
                               recipient.
                              --in a vaccine        Not applicable.
                               associated
                               community case.
                              B. Vaccine-Strain     ....................
                               Polio Viral
                               Infection.
                              --in a non-           <=30 days.
                               immunodeficient
                               recipient.
                              --in an               <=6 months.
                               immunodeficient
                               recipient.
                              --in a vaccine        Not applicable.
                               associated
                               community case.
VII. Vaccines containing      A. Anaphylaxis......  <=4 hours.
 polio inactivated virus
 (e.g., IPV).
VIII. Hepatitis B vaccines..  A. Anaphylaxis......  <=4 hours.
IX. Haemophilus influenzae    No Condition          Not applicable.
 type b (Hib) vaccines.        Specified.
X. Varicella vaccines.......  A. Anaphylaxis......  <=4 hours.
                              B. Disseminated
                               varicella vaccine-
                               strain viral
                               disease.
                              --Vaccine-strain      Not applicable.
                               virus identified.
                              --If strain           7-42 days (not less
                               determination is      than 7 days and not
                               not done or if        more than 42 days).
                               laboratory testing
                               is inconclusive.
                              C. Varicella vaccine- Not applicable.
                               strain viral
                               reactivation.
XI. Rotavirus vaccines......  A. Intussusception..  1-21 days (not less
                                                     than 1 day and not
                                                     more than 21 days).
XII. Pneumococcal conjugate   No Condition          Not applicable.
 vaccines.                     Specified.
XIII. Hepatitis A vaccines..  No Condition          Not applicable.
                               Specified.
XIV. Seasonal influenza       A. Anaphylaxis......  <=4 hours.
 vaccines.
                              B. Guillain-          3-42 days (not less
                               Barr[egrave]          than 3 days and not
                               Syndrome.             more than 42 days).
XV. Meningococcal vaccines..  A. Anaphylaxis......  <=4 hours.
XVI. Human papillomavirus     A. Anaphylaxis......  <=4 hours.
 (HPV) vaccines.
------------------------------------------------------------------------

* * * * *
[FR Doc. 2020-15673 Filed 7-16-20; 4:15 pm]
BILLING CODE 4165-15-P