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NOTICE: This opinion is subject to formal revision before publication in the
preliminary print of the United States Reports.  Readers are requested to
notify the Reporter of Decisions, Supreme Court of the United States, Wash-
ington, D.C. 20543, of any typographical or other formal errors, in order that
corrections may be made before the preliminary print goes to press.
SUPREME COURT OF THE UNITED STATES
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No. 94-372
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DONNA E. SHALALA, SECRETARY OF HEALTH
AND HUMAN SERVICES, PETITIONER v.
 MARGARET WHITECOTTON et al.
on writ of certiorari to the united states court
of appeals for the federal circuit
[April 18, 1995]

  Justice Souter delivered the opinion of the Court.
  The question in this case is whether a claimant who
shows that she experienced symptoms of an injury after
receiving a vaccination makes out a prima facie case for
compensation under the National Childhood Vaccine
Injury Act, 100 Stat. 3755, 42 U. S. C. 300aa-1 et seq.
(1988 ed. and Supp. V), where the evidence fails to
indicate that she had no symptoms of that injury before
the vaccination.  We hold that the claimant does not
make out a case for compensation.

                               I
  For injuries and deaths traceable to vaccinations, the
Act establishes a scheme of recovery designed to work
faster and with greater ease than the civil tort system.
H. R. Rep. No. 99-908, pp. 3-7 (1986).  Special masters
in the Court of Federal Claims hear vaccine-related
complaints, 42 U. S. C. 300aa-12(c) (1988 ed., Supp. V),
which they adjudicate informally, 300aa-12(d)(2), within
strict time limits, 300aa-12(d)(3)(A), subject to similarly
expeditious review, 300aa-12(e)(2).  A claimant alleging
that more than $1,000 in damages resulted from a
vaccination after the Act's effective date in 1988 must
exhaust the Act's procedures and refuse to accept the
resulting judgment before filing any de novo civil action
in state or federal court.  42 U. S. C. 300aa-11(a)
(1988 ed. and Supp. V).
  The streamlining does not stop with the mechanics of
litigation, but goes even to substantive standards of
proof.  While a claimant may establish prima facie
entitlement to compensation by introducing proof of
actual causation, 300aa-11(c)(1)(C)(ii), she can reach
the same result by meeting the requirements of what
the Act calls the Vaccine Injury Table.  The table lists
the vaccines covered under the Act, together with
particular injuries or conditions associated with each
one.  42 U. S. C. 300aa-14 (1988 ed., Supp. V).  A
claimant who meets certain other conditions not relevant
here makes out a prima facie case by showing that she
(or someone for whom she brings a claim) -sustained, or
had significantly aggravated, any illness, disability,
injury, or condition set forth in the Vaccine Injury Table
in association with [a] vaccine . . . or died from the
administration of such vaccine, and the first symptom or
manifestation of the onset or of the significant aggrava-
tion of any such illness, disability, injury, or condition or
the death occurred within the time period after vaccine
administration set forth in the Vaccine Injury Table.-
42 U. S. C. 300aa-11(c)(1)(C)(i).  Thus, the rule of
prima facie proof turns the old maxim on its head by
providing that if the post hoc event happens fast, ergo
propter hoc.  The Secretary may rebut a prima facie case
by proving that the injury or death was in fact caused
by -factors unrelated to the administration of the vaccine
. . . .-  300aa-13(a)(1)(B).  If the Secretary fails to
rebut, the claimant is entitled to compensation.  42
U. S. C. 300aa-13(a)(1) (1988 ed. and Supp. V).
  Respondents, Margaret Whitecotton and her parents,
filed a claim under the Act for injuries Margaret
allegedly sustained as a result of vaccination against
diphtheria, pertussis, and tetanus (or DPT) on August
18, 1975, when she was nearly four months old.  They
alleged that Margaret (whom we will refer to as claim-
ant) had suffered encephalopathy after the DPT vaccina-
tion, and they relied on the table scheme to make out a
prima facie case.  The Act defines encephalopathy as
-any significant acquired abnormality of, or injury to, or
impairment of function of the brain,-  42 U. S. C.
300aa-14(b)(3)(A), and lists the condition on the
Vaccine Injury Table in association with the DPT
vaccine.  Under the Act, a claimant who does not prove
actual causation must show that -the first symptom or
manifestation of the onset or of the significant aggrava-
tion- of encephalopathy occurred within three days of a
DPT vaccination in order to make out a prima facie
right to compensation.  300aa-11(c)(1)(C)(i); 42 U. S. C.
300aa-14(a) (1988 ed., Supp. V).
  The Special Master found that the claimant had
suffered clonic seizures on the evening after her vaccina-
tion and again the following morning, App. to Pet. for
Cert. 24a, 27a, and accepted those seizures as symptoms
of encephalopathy.  He also found, however, that by the
time the claimant received the vaccination she was
-clearly microcephalic- (meaning that she had a head
size more than two standard deviations below the mean
for a girl her age) and that her microcephaly was a
symptom or evidence of encephalopathy that existed
before the vaccination.  Id., at 32a-33a.  Accordingly,
the Master concluded that the first symptom or manifes-
tation of the onset of claimant's encephalopathy had
occurred before the vaccination and the ensuing three-
day period provided for in the table.  Id., at 34a.
  The Master then considered whether the series of
seizures was -the first symptom or manifestation . . . of
[a] significant aggravation- of the claimant's encephalop-
athy, 42 U. S. C. 300aa-11(c)(1)(C)(i), and again
decided that it was not.  The Act defines -significant
aggravation- as -any change for the worse in a preexist-
ing condition which results in markedly greater disabil-
ity, pain, or illness accompanied by substantial deterio-
ration of health.-  300aa-33(4).  The Master found that
-[t]here is nothing to distinguish this case from what
would reasonably have been expected considering
[claimant's] microcephaly . . . . [T]here was nothing that
occurred in temporal relationship to the DPT vaccination
which indicates that it is more likely than not that the
vaccine permanently aggravated her condition . . . .
[T]he seizures did not continue and there was no
dramatic turn for the worse in her condition . . . . Thus,
there is no basis for implicating the vaccine as the cause
of any aspect of [claimant's] present condition.-  App. to
Pet. for Cert. 41a-43a.  Because he found that the
claimant had failed to satisfy the table requirements,
and had not tried to prove actual causation, the Master
denied her compensation for failure to make out a prima
facie case.
  The Court of Federal Claims found the Master's
decision neither arbitrary nor otherwise unlawful, see 42
U. S. C. 300aa-12(e)(2) (1988 ed., Supp. V), and
affirmed.  The Court of Appeals for the Federal Circuit
then reversed, holding that a claimant satisfies the table
requirements for the -first symptom or manifestation of
the onset- of an injury whenever she shows that any
symptom or manifestation of a listed condition occurred
within the time period after vaccination specified in the
table, even if there was evidence of the condition before
the vaccination.  Because claimant here showed symp-
toms of encephalopathy during the 3-day period after her
DPT vaccination, the Court of Appeals concluded for that
reason alone that she had made out a prima facie
entitlement to recovery.  17 F. 3d 374, 376-377 (1994).
  The Court of Appeals went on to say that the Secre-
tary had failed to rebut this prima facie case because
she had not shown that claimant's encephalopathy was
caused by -factors unrelated to the administration of the
vaccine,- 42 U. S. C. 300aa-13(a)(1)(B).  The Court of
Appeals relied on the provision that a -facto[r] un-
related- cannot include an -idiopathic- condition,
300aa-13(a)(2)(A), which the court read to mean that
even when the Secretary can point to a specific factor,
unrelated to the vaccine, as the source of a claimant's
injury, she does not defeat a prima facie case when the
cause of the identified factor is itself unknown.  Taking
the Secretary to have relied on claimant's microcephaly
as the unrelated factor (or as associated with it), the
court ruled the Secretary's evidence insufficient on the
ground that the cause of microcephaly is unknown.  17
F. 3d, at 377-378.
  We granted certiorari to address the Court of
Appeals's construction of the Act's requirements for
making and rebutting a prima facie case.  Because we
hold that the court erroneously construed the provisions
defining a prima facie case under the Act, we reverse
without reaching the adequacy of the Secretary's
rebuttal.

                              II
  The Court of Appeals declared that nowhere does the
Act -expressly state- that a claimant relying on the table
to establish a prima facie case for compensation must
show -that the child sustained no injury prior to
administration of the vaccine,- that is, that the first
symptom of the injury occurred after vaccination.  17
F.3d, at 376.  This statement simply does not square
with the plain language of the statute.  In laying out
the elements of a prima facie case, the Act provides that
a claimant relying on the table (and not alleging signifi-
cant aggravation) must show that -the first symptom or
manifestation of the onset . . . of [her table illness] . . .
occurred within the time period after vaccine admin-
istration set forth in the Vaccine Injury Table.-
300aa-11(c)(1)(C)(i).  If a symptom or manifestation of
a table injury has occurred before a claimant's vaccina-
tion, a symptom or manifestation after the vaccination
cannot be the first, or signal the injury's onset.  There
cannot be two first symptoms or onsets of the same
injury.  Thus, a demonstration that the claimant
experienced symptoms of an injury during the table
period, while necessary, is insufficient to make out a
prima facie case.  The claimant must also show that no
evidence of the injury appeared before the vaccination.
  In coming to the contrary conclusion, the Court of
Appeals relied on language in the table, which contains
the heading, -Time period for first symptom or manifes-
tation of onset . . . after vaccine administration.-  42
U. S. C. 300aa-14(a) (1988 ed., Supp. V).  The Court of
Appeals saw a -significant- distinction, 17 F. 3d, at
376, between this language and that of 42 U. S. C.
300aa-11(c)(1)(C)(i), which is set forth above.  We do
not.  The key to understanding the heading is the word
-onset.-  Since the symptom or manifestation occurring
after the vaccination must be evidence of the table
injury's onset, an injury manifested before the vaccina-
tion could qualify only on the theory that it could have
two onsets, one before the vaccination, one after it.  But
it cannot: one injury, one onset.  Indeed, even if the
language of the heading did conflict with the text of
300aa-11(c)(1)(C)(i), the latter would prevail, since the
table heading was obviously meant to be a short form of
the text preceding it.
  The Court of Appeals sought to shore up the contrary
conclusion with two further arguments.  As the court
read the Act, Congress -expressly made the absence of
preexisting injury an element of the prima facie case-
for residual seizure disorder (another table injury), 17
F. 3d at 376; thus, the court reasoned, Congress had
implicitly rejected any need to negate the pre-existence
of other injuries like encephalopathy.  This argument
rests on a misreading of the language in question.  The
statutory notes explaining the table provide that a
claimant -may be considered to have suffered a residual
seizure disorder if [she] did not suffer a seizure or
convulsion unaccompanied by fever or accompanied by a
fever of less than 102 degrees Fahrenheit before the first
seizure or convulsion after the administration of the
vaccine involved . . . .-  300aa-14(b)(2).  But this is not
the language that requires a claimant alleging a seizure
disorder to demonstrate the absence of pre-existing
symptoms.  This provision specifies instead that certain
types of seizures (those accompanied by a high fever)
may not be considered symptoms of residual seizure
disorder, and, so, do not preclude a prima facie case
even when a claimant suffered them before vaccination.
The language carries no implication about a claimant's
burden generally and does nothing to undermine
Congress's global provision that a claimant who has
actually suffered symptoms of a listed injury before
vaccination cannot make out a prima facie case of the
injury's onset after vaccination.
  Finally, we cannot accept the Court of Appeals's argu-
ment that because the causal -factors unrelated- on
which the Secretary may rely to defeat a prima facie
case can include occurrences before vaccination, see
300aa-13(a)(2)(B), such occurrences cannot bar the
establishment of a prima facie case in the first instance.
The -factors unrelated- provision is wholly independent
of the first-symptom and onset provisions, serving the
distinct purpose of allowing the Secretary to defeat a
claim even when an injury has not manifested itself
before vaccination.  It does not relieve a claimant of the
clear statutory requirements for making out a prima
facie case.

                              III
  The judgment of the Court of Appeals for the Federal
Circuit is accordingly reversed and the case remanded
for further proceedings consistent with this opinion.

                                            It is so ordered.