WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20100025
OBJECTION BY: Worker
PARTICIPANTS: Worker, Worker’s representative
ISSUE
The worker maintains she developed a skin condition on her hands and feet because of flu vaccines (i.e., based on egg culture) that she received at work in December 1999, October 2000 and October 2001.
HOW THE ISSUE ARISES
The worker registered a claim in July 2002. She maintains that she is allergic to eggs, a component of the flu vaccine. There are no medical reports on file about the three reactions she said she had in 1999, 2000 and 2001. The first medical report on file is dated April 3, 2002 from the allergist. The allergist found no evidence to any IGE allergy to egg upon skin testing. He indicated the skin test results were negative four times. They were also negative for the flu vaccine, neomycin and latex. Because of the possibility of a delayed or cell-mediated allergy, he planned to arrange skin patch testing for egg and a possible oral challenge. If these turned out to be negative, then it was possible the worker had psoriasis and a referral to a dermatologist would be arranged.
His next report of April 11, 2002, however, offered few details about the skin patch testing or oral challenge. He simply indicated that the worker had experienced “an acute systemic allergic reaction to an oral challenge of one egg.” It is unclear whether he administered the oral challenge himself or whether the worker ate egg on her own initiative at home. However, the worker later reportedly told Specialist A at the Occupational Health Clinic at St. Michael’s Hospital that the oral challenge had not occurred under medical supervision. Instead, she had eaten an egg at home on her own initiative. See report dated December 17, 2002.
Examination at the Occupational Health Clinic in December 2002 revealed some erythema on the worker’s palms and soles. The worker told Specialist A that she had developed headaches, ear pain, a pounding feeling in her heart and a relatively mild rash on her hands following the first flu vaccine in December 1999. The rash was mainly on the index finger (which one?) and the thumb tips. It was thought that latex might be the culprit and she was switched from latex to vinyl gloves but her index finger and thumbs continued to be irritated. She also continued to have daily headaches and pain in her ears.
In the autumn of 2000, she had another vaccine and shortly afterwards, the rash extended to the thenar and hypothenar areas of her hands. According to her, the headaches, ear pain and heart palpitations worsened. Multiple tests and a chest x-ray were all negative. The rash flared and receded but never disappeared completely afterwards. She continued to work and ate all foods including eggs.
In October 2001, she had a third flu shot and shortly afterwards developed significant swelling of the palms and feet. The rash involved the entire surface of the palms and soles as well as the lateral and medial aspects of her feet. The intensity of the rash varied. She also experienced headaches, periorbital swelling and swelling under her ears.
She told Specialist A that she began to wonder about possible food allergies. She was tested by her own allergist but the tests were all negative. She tested herself at home on April 5, 2002 by eating an egg and developed headaches, swelling around the eyes and ears within 15 minutes but did not develop any rash on her hands other than “a mild pruritus lasting a few hours.”
Since May 2002, she had experienced seven severe flare-ups of the rash on her palms and soles. She had only been able to work eight weeks between May 2002 and December 2002.
Specialist A was not convinced that the worker was allergic to eggs. He noted that the flu vaccine contains formaldehyde and the possibility of other contact sensitivities existed such as rubber congeners, cleaning fluids, formaldehyde and phenol-formaldehyde. He did not think that appropriate conclusions could be drawn from the worker’s self-challenge ingesting an egg at home and recommended that any challenge testing be done in the presence of a doctor, preferably an allergist.
In addition, the worker was assessed by Specialist B at the Occupational Health Clinic on March 3, 2003. Specialist B noted that the worker had been off work for over a year and had avoided eating eggs yet she still had severe hand and foot eczema. The worker was patch tested extensively according to the standard tray, the health personnel tray, phenoformaldehyde resin, di-limonene (present in some cleaning products), thiomersal (preservative used in Vaxigrip vaccine), all of her different gloves and hydrocortisone and all its different variants. The patch test results were negative except for nickel and cobalt. She was negative to all the glove samples, the accelerators in the gloves, the health personnel series and thiomersal, the preservative in the vaccine. An oral challenge with a cooked egg was done and the result was negative. A piece of egg was placed on her forearm for 30 minutes and the result was negative.
Specialist B noted that there was no association in the medical literature between egg protein and dermatitis although egg protein could cause urticaria (swelling and redness for 24 hours). Specialist B indicated there was a discrepancy in the outcome of the oral egg challenge she had administered and that reportedly administered by the worker’s allergist on April 5, 2002. She commented that the worker may have had a systemic reaction when the allergist had administered the oral egg challenge but this did not explain the dermatitis on her hands and feet. The flu vaccine had nothing to do with the eruption on her hands and feet. Specialist B thought the worker had a genetic eczema or psoriform eczema that was chronic and recurrent and the timing with the vaccine shot may have been coincidental.
The adjudicator reviewed these medical opinions and findings and concluded there was no evidence that the dermatitis on the worker’s hands and feet was related to the flu vaccine or an egg allergy. See letter dated April 15, 2003. The worker objected to this decision.
The worker underwent repeat testing with her allergist on September 11, 2003 and from September 29 to October 2, 2003. The allergist reported that skin testing for immediate IgE mediated allergy to egg and patch testing for delayed cell-mediated allergy were again negative. An oral challenge with raw egg was negative. He concluded, “This effectively ruled out egg as a possible cause of her dermatitis.”
The worker also underwent a direct administration of the full dose (0.5 ml.) of the 2003 Vaxigrip vaccine. During the next 72 hours, there was no deterioration observed in her dermatitis. The doctor concluded, “This effectively rules out the present flu vaccine as a cause for her dermatitis.” The worker, on the other hand, told the adjudicator that she experienced vomiting, diarrhea and severe flu symptoms following the repeat vaccine in the autumn of 2003. See memo # 31.
The allergist referred the worker to a dermatologist for assessment of her dermatitis. He also noted that she was significantly hampered by joint pain and stiffness and referred her to a rheumatologist. See report dated October 3, 2003.
The dermatologist commented that her skin changes are “most definitely psoriasiforme in nature and whether this is true psoriasis or a psoriasiforme exzema is not possible to distinguish. “I cannot relate this to her vaccine and the timing of the onset of her problems may simply (sic) coincidental.” See reports dated May 18, 2004.
The worker’s representative submitted some information she had received from Occupational Health Clinics for Ontario Workers on the adverse effects of vaccines. She also commented that testing at St. Michael’s Hospital had revealed allergies to cobalt and nickel of which the worker had been unaware. The representative commented that the worker developed her illness “closely to the time of the vaccines” and, hence, it was reasonable to believe that the vaccines played a significant role in making the worker more sensitive to nickel and cobalt. See letter dated February 18, 2004.
The WSIB’s medical consultant asked Specialist A and Specialist B at the Occupational Health Clinic to comment on the various documents submitted by the worker’s representative. Specialist A reviewed the evidence again concerning a possible egg allergy and commented, “I am satisfied that egg allergy is not responsible for the adverse reaction experienced following the patient having received Vaxigrip vaccine.” He discounted the representative’s view that the worker could have developed allergies to cobalt and nickel from the Vaxigrip vaccine. He also indicated there was no evidence of frequent and significant exposures to nickel and cobalt to account for the nickel and cobalt sensitivity. He cautioned against reliance upon the material the worker’s representative had submitted because it was prepared by an organization that advocated against the use of vaccines. He commented on the organization’s positions on various unrelated matters and indicated its positions had been refuted by the medical literature.
He said that, since the dermatitis was said to follow the administration of the vaccine, he could not rule out a cause and effect relationship altogether. He speculated that perhaps it was the killed flu virus in the vaccine that might explain a possible relationship. However, he was satisfied that eggs were not responsible for the worker’s illness. He also could not explain why the dermatitis had continued to be symptomatic. See letter dated August 9, 2004.
Specialist B reiterated her view that the vaccines were not responsible for the skin problems. She also did not support the representative’s theory that the vaccines played a significant role in making the worker more sensitive to nickel and cobalt. She indicated that many allergies can be uncovered during patch testing which are irrelevant to a patient’s active symptoms. She also indicated that positive reactions to nickel and cobalt are very common among women. About 10% of women in North America are allergic to nickel and cobalt from wearing costume jewellery over their lifetime.
She commented that the only evidence to support a relationship between the flu vaccines and the worker’s hand and foot eczema is temporal. “There is no medical or clinical evidence to suggest otherwise.” See letter dated August 9, 2004.
In September 2004, the dermatologist reported that the worker had been improving with treatment but she wanted to see if eggs would cause a reactivation of her symptoms. She told the doctor that she had eaten eggs about a week before and had developed headaches, nausea and a worsening of her skin condition. The dermatologist noted that she had erythema, thickening and fissuring of the palms of her hands and more urticarial type lesions on her trunk. The doctor commented that the hands were “definitely psoriasiforme in nature” and food allergies are not directly related to psoriasis “although in the worker seems to have worsened after ingestion of eggs.” He went on to add, “I simply cannot make any meaningful comment as to the relationship between egg sensitivity and, more importantly, her presumed reaction to her vaccine and her ongoing skin problem.” See letter dated September 22, 2004.
The adjudicator did not change her previous decision. See letter dated August 16, 2004 and the matter was referred to the Appeals Branch. The appeal was withdrawn in October 2005 but has recently been reactivated.
AUTHORITY REFERENCE
Operational policy 11-01-01 Adjudicative Process”
ASSESSMENT OF EVIDENCE AND SUBMISSIONS
The worker’s representative chose the 60 day paper review option meaning he wants a decision within 60 days based on the file record and any additional evidence or submissions he attached to the 60 day decision option form. He submitted another doctor’s letter dated July 23, 2009. I presume this doctor is the worker’s current general practitioner. The general practitioner advocated a review of the case based on the temporal relationship between the worker’s reactions and the three flu vaccines.
Having reviewed the file record and the worker’s additional submission, I cannot conclude that her skin condition is the result of the three flu vaccines in 1999, 2000 and 2001. The reasons are as follows:
There is no medical support at all for the worker’s contention that the flu vaccines and/or an egg allergy caused the skin condition on her hands and feet. See reports from the allergist, Specialist A, Specialist B and the dermatologist.
She has been repeatedly tested for a possible connection but, with the exception of the flu vaccine administered by the allergist in September 2003, the tests have been unequivocally negative.
The evidence concerning the administration of the vaccine in September 2003 is contradictory in that the allergist said he had observed no adverse reactions over the 72 hours after the administration of the vaccine. The worker, on the other hand, told the adjudicator that she was ill afterwards. There is no way to resolve this contradiction given the information currently on the file record.
As Specialist A and Specialist B had indicated, the only evidence of a possible connection to the flu vaccines is a temporal one, i.e., the worker said she experienced reactions following the administration of four flu vaccinations.
The worker now advocates a relationship on the basis of a temporal connection between the development of her symptoms and the administration of the vaccines. However, a temporal association is the weakest form of evidence in this case and even a temporal association is not demonstrated on the file record. There are no relevant medical records on file to confirm her reactions immediately following the administration of the vaccines in 1999, 2000 and 2001 and 2003. The medical records on file do not begin until April 3, 2002. Therefore, there is no actual proof of a temporal relationship contained in the file record.
Finally, Specialist A and Specialist B wondered why the symptoms would persist so long after the administration of the flu vaccines. This tends not to support the view that the flu vaccines are responsible for the development and persistence of the skin condition.
For these reasons, I cannot conclude that the workers’ skin condition is the result of the flu vaccines (i.e., egg culture) that were administered in 1999, 2000, and 2001.
CONCLUSION
There is no evidence to support the conclusion that flu vaccines (i.e., egg culture) administered in 1999, 2000 and 2001 led to the development of the worker’s skin condition on her hands and feet.
The worker’s objection is denied.
DATED January 20, 2010
R. Nestereiczyk
Appeals Resolution Officer
Appeal Branch