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Case Details (Sorted by Age)

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VAERS ID: 219909 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-04-29
Onset:2004-04-30
   Days after vaccination:1
Submitted: 2004-05-07
   Days after onset:7
Entered: 2004-05-04
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 602A2 / 3 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1582 / 4 RL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0179N / 2 RA / SC

Administered by: Private       Purchased by: Other
Symptoms: Injection site erythema, Injection site oedema, Injection site warmth
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Advil for discomfort;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 04/01/04: Left thigh with redness and slight swelling and warm to touch. Deferred to MD to evaluate.


VAERS ID: 219929 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Wisconsin  
Vaccinated:2004-04-14
Onset:2004-04-14
   Days after vaccination:0
Submitted: 2004-05-04
   Days after onset:20
Entered: 2004-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM A622A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0566 / 4 RA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0808N / 2 RA / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0885N / 1 LA / SC

Administered by: Private       Purchased by: Private
Symptoms: Angioneurotic oedema, Dysphonia, Erythema, Pruritus, Rash, Respiratory distress
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Parkinson-like events (broad), Oropharyngeal allergic conditions (narrow), Acute central respiratory depression (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Adderall
Current Illness: None.
Preexisting Conditions: ADHD.
Allergies:
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Approximately 1 hour after immunizations were administered, patient''s mother called clinic stating patient had a red rash all over her body which was very itchy and patient was also complaining of feeling like there was a horse in her throat. Parents were instructed to bring her back immediately. They arrived within 10-15 minutes. She was noted to have a highly erythematous rash from head to toe which was quite pruritic. No angioedema or respiratory distress. She was treated with an IM injection of Benadryl and a SQ injection of epinephrine. Her symptoms resolved very quickly.


VAERS ID: 219947 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Oregon  
Vaccinated:2004-04-20
Onset:2004-04-20
   Days after vaccination:0
Submitted: 2004-04-22
   Days after onset:2
Entered: 2004-05-05
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1272AA / 5 LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Pruritus, Rash erythematous, Swelling, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: OR200412

Write-up: Within 15 min after injection, Pt broke out in hives all over body. Referred to PMD or ER. Seen at Medical ctr. with itching, red rash, swollen Right wrist due to hives. Tx''d with Benadryl 12.5 mg po, continue as needed through night.


VAERS ID: 219954 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: New York  
Vaccinated:0000-00-00
Onset:2004-04-29
Submitted: 2004-04-30
   Days after onset:1
Entered: 2004-05-05
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Private       Purchased by: Private
Symptoms: Agitation, Crying, Pruritus, Rash
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Depression (excl suicide and self injury) (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was hysterical at time of vac. administered. Did not calm down after 20 min. Mom left with child. Gave Motrin, child fell asleep, woke up shortly after itching head and blotchy rash over trunk and extremities. Returned to office for evaluation.


VAERS ID: 219956 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Massachusetts  
Vaccinated:2004-04-27
Onset:2004-04-28
   Days after vaccination:1
Submitted: 2004-04-29
   Days after onset:1
Entered: 2004-05-05
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR 91272DA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0313 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0808N / 2 RA / SC

Administered by: Public       Purchased by: Unknown
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Erythema on Left shoulder 9x12cms


VAERS ID: 219967 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-04-27
Onset:2004-04-28
   Days after vaccination:1
Submitted: 2004-04-29
   Days after onset:1
Entered: 2004-05-05
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 592B9 / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0703 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0179N / 2 LA / -

Administered by: Private       Purchased by: Unknown
Symptoms: Erythema, Feeling hot, Oedema, Tenderness
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Left arm red, warm to touch, sl. tender, swollen about 8-10 cm.


VAERS ID: 219982 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Pennsylvania  
Vaccinated:2004-04-26
Onset:2004-04-27
   Days after vaccination:1
Submitted: 2004-04-28
   Days after onset:1
Entered: 2004-05-05
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 552A2 / UNK RA / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER W0704 / UNK LA / IM
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER 0339M / UNK LA / SC

Administered by: Private       Purchased by: Unknown
Symptoms: Injection site erythema, Injection site swelling
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 1.5cm reddness at both sites swelling at DTaP. Otherwise feels fine.


VAERS ID: 219984 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Maryland  
Vaccinated:2004-04-05
Onset:2004-04-06
   Days after vaccination:1
Submitted: 2004-04-27
   Days after onset:21
Entered: 2004-05-05
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1612AA / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0554 / 4 RA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0613N / 2 LA / SC

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Feeling hot, Swelling, Tenderness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Mom mentioned at a sick visit 4/27/04 that the day after the pt received her 4 yr vaccines. DTaP, MMR, IV that her left upper arm including shoulder were red, swollen, tender and warm. It resolved after one week with no treatment. At 4/27/04 the left arm was completely normal.


VAERS ID: 220003 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Texas  
Vaccinated:2004-03-17
Onset:2004-03-18
   Days after vaccination:1
Submitted: 2004-03-19
   Days after onset:1
Entered: 2004-05-06
   Days after submission:47
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1272BA / 4 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0706 / 5 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0609N / 2 LA / SC

Administered by: Military       Purchased by: Military
Symptoms: Cellulitis, Injection site erythema, Injection site induration, Injection site pain, Injection site reaction
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol on 18MAR04
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Three vaccines placed in arm with erythema/induration/ pain starting the following day. By 48hours pt had cellulitis.


VAERS ID: 220065 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Illinois  
Vaccinated:2004-05-04
Onset:2004-05-05
   Days after vaccination:1
Submitted: 2004-05-06
   Days after onset:1
Entered: 2004-05-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 616A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1619 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0275N / 2 RA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Oedema
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: no
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: none
CDC Split Type:

Write-up: mother stated arm had small red area evening of 5/4/04 but by evening of 5/5/04 l arm was swollen & red from shoulder to elbow


VAERS ID: 220026 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Idaho  
Vaccinated:2004-03-24
Onset:2004-03-25
   Days after vaccination:1
Submitted: 2004-04-08
   Days after onset:13
Entered: 2004-05-07
   Days after submission:29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM A601A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0816 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0396N / 2 RA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Injection site pain, Pruritus, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: ID04020

Write-up: Complained of pain at injection site ; left deltoid where she got her DTaP that day. Woke up with redness, swelling, itching and pain in the area. Seen in office to eval.


VAERS ID: 220030 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Texas  
Vaccinated:2004-04-27
Onset:2004-04-29
   Days after vaccination:2
Submitted: 2004-04-30
   Days after onset:1
Entered: 2004-05-07
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1272CA / 5 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0148 / 4 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0391N / 2 RA / SC

Administered by: Public       Purchased by: Unknown
Symptoms: Injection site erythema, Injection site rash, Injection site swelling, Rash maculo-papular
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: Penicillin
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 4-29: grandmother noticed red swollen area on right leg (area of DTaP inj). 4-30: brought to clinic, has large 3"x4" "splotchy" type rash on right upper leg in the area of the DTaP injection. Not warm to the touch, not swollen. Grandmother says it is better today after taking benadryl. Taking him to Dr.


VAERS ID: 220034 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Arkansas  
Vaccinated:2004-04-20
Onset:2004-04-21
   Days after vaccination:1
Submitted: 2004-04-23
   Days after onset:2
Entered: 2004-05-07
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 627A2 / 5 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0816 / 4 RA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1126M / 2 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Feeling hot, Pyrexia, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: AR0428

Write-up: 1) fever up to 100.0 degrees mother states 2) red swollen area warm to touch on RUA about 5x5 and 1/2 cm in size.


VAERS ID: 220040 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Texas  
Vaccinated:2004-04-27
Onset:2004-04-28
   Days after vaccination:1
Submitted: 2004-05-01
   Days after onset:3
Entered: 2004-05-07
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1624AA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1156 / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0137D / 2 LA / SC

Administered by: Private       Purchased by: Private
Symptoms: Injection site induration, Skin hyperpigmentation
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Slight induration with overlying hyperpigmentation. No treatment necessary


VAERS ID: 220047 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Colorado  
Vaccinated:2004-04-26
Onset:2004-04-27
   Days after vaccination:1
Submitted: 2004-04-28
   Days after onset:1
Entered: 2004-05-07
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / UNK LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0707 / UNK LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0955N / UNK RA / -

Administered by: Private       Purchased by: Unknown
Symptoms: Erythema, Feeling hot, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Left upper arm with moderate swelling and mild redness and warmth also tender to palpate no respiratory sx''s


VAERS ID: 220049 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Colorado  
Vaccinated:2004-04-27
Onset:2004-04-28
   Days after vaccination:1
Submitted: 2004-04-30
   Days after onset:2
Entered: 2004-05-07
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR 9625AA / 5 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0214 / 4 RL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0810N / 2 RL / -

Administered by: Public       Purchased by: Other
Symptoms: Injection site erythema, Injection site oedema
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Erythema/edema left thigh at vaccination site. Started on 04/28/04 with slight redness, 04/29/04 swollen and increased red.


VAERS ID: 220073 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-04-20
Onset:2004-04-20
   Days after vaccination:0
Submitted: 2004-04-30
   Days after onset:10
Entered: 2004-05-10
   Days after submission:10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 630A2 / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0368 / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (VIRIVAC) / MERCK & CO. INC. 0952 / 2 RL / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Swelling, Tenderness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Child developed red tender swelling left thigh which required hospitalization 04/21/04/23/04 at medical center . He did not have fever. Child was treated with IV antibiotic and discharged on oral Abx, Benadryl.


VAERS ID: 220083 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Arkansas  
Vaccinated:2004-04-20
Onset:2004-04-21
   Days after vaccination:1
Submitted: 2004-04-22
   Days after onset:1
Entered: 2004-05-10
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 627A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0816 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1126M / 2 RA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Injection site warmth, Pyrexia, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: AR0430

Write-up: Fever 100-101 degrees. Mother states left upper arm with redness and swollen area 8x9cm- warm to touch at injection site of DTaP. Started with smaller area of swelling on 4/21/04 at about 8:00 am when mom noticed it.


VAERS ID: 220091 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Oregon  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-06
   Days after onset:2
Entered: 2004-05-10
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0707 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0812N / 2 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site induration, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Slightly erythematous, indurated area where vaccine given: left upper arm and fever of 103.0 (temp)


VAERS ID: 220111 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: North Carolina  
Vaccinated:2004-05-07
Onset:2004-05-07
   Days after vaccination:0
Submitted: 2004-05-10
   Days after onset:3
Entered: 2004-05-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1258DA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR XO553 / 4 LL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0809N / 2 RL / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Rash
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT PRESENTED WITH RASH ON R LEG. RED, BUMPY, NO PAIN AFTER 1 DAY.


VAERS ID: 220122 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Arizona  
Vaccinated:2003-02-10
Onset:2003-02-25
   Days after vaccination:15
Submitted: 2004-08-19
   Days after onset:540
Entered: 2004-05-11
   Days after submission:100
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS SS7A2 / 5 LL / -
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 1061M / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0460 / 4 RL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1008M / 2 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Abdominal pain upper, Abnormal behaviour, Alopecia, Amnesia, Diarrhoea
SMQs:, Acute pancreatitis (broad), Dementia (broad), Pseudomembranous colitis (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Allergy to soy and peanut products.
Allergies:
Diagnostic Lab Data:
CDC Split Type: 200401713

Write-up: From initial information received on 4/27/04 regarding an adverse event occurring in the USA, it was reported that a four year old male patient received an IPOL vaccination, lot number W0460, administered in the right thigh, an MMR II vaccination, lot number 644415/1008M, administered in the left arm, a VAQTA vaccination, lot number 643816/1061M, administered in the right thigh, and an INFANRIX vaccination, lot number SS7A2, administered in the left thigh on 2/10/03. 15 days later on 2/25/03, a registered dietitian reported that in February 2003, the patient lost all of his hair. The patient''s mother noticed a patch on the back of the boy''s head the day after vaccination, and within two weeks all of his hair was gone. On 1/14/04, the patient''s hair had not returned. In follow up information received from the patient''s mother, it was reported that the patient had allergies to soy and peanut products. She also reported that on 2/10/03, the patient received his second dose of VAQTA. The first dose was given on 12/11/03. It was reported that the patient was not ill at the time of vaccination. The reporter indicated that the patient received four shots in one day and about two weeks later, on 2/25/03, the patient had bad stomach aches and had to go to the doctor for diarrhea. Reportedly, the patient woke up with a bald spot the size of a quarter and within three months he had no hair, eyebrows, or eyelashes. The patient''s mother noticed a different behavior, almost like she had a different child. She reported that the patient had memory loss on and off. The change in the patient''s behavior was noticed by the mother after vaccination with VAQTA on 2/10/03. According to the reporter, the physician diagnosed the patient with alopecia. The patient''s experiences were considered to be disabling by the patient''s mother. Additional information has been requested. The patient has not recovered from these events. From additional information received on 10/May/2004 from another manufacturer, ID number WAES0401USA01070, it was reported that the change in the patient''s behavior was noticed by the mother after vaccination with the first dose of hepatitis A virus vaccine inactivated (manufacturer, lot number and administration information not reported) on 11/Dec/2002 (also reported as 11/Dec/2003) and the hair loss after vaccination with the second dose of hepatitis A virus vaccine inactivated on 10/Feb/2003. This report was previously sent to PLA V205C.


VAERS ID: 220128 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-04-26
Onset:2004-04-27
   Days after vaccination:1
Submitted: 2004-04-28
   Days after onset:1
Entered: 2004-05-11
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1354AA / UNK LA / IM
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0159P / UNK RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1233 / UNK LA / SC

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Feeling hot, Injection site induration, Swelling, Tenderness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Swelling, erythema , minimal tenderness, marked warmth, mild induration Left upper outer arm extending from just below shoulder to just below elbow on day after injection, increasing throughout the day. Seen around 3:40 after injection.


VAERS ID: 220131 (history)  
Form: Version 1.0  
Age: 4.5  
Gender: Male  
Location: Pennsylvania  
Vaccinated:2004-04-16
Onset:2004-04-16
   Days after vaccination:0
Submitted: 2004-05-04
   Days after onset:18
Entered: 2004-05-11
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0814N / 2 - / SC

Administered by: Private       Purchased by: Private
Symptoms: Crying, Erythema, Pruritus, Rash, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Depression (excl suicide and self injury) (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Captropril, Aspirin
Current Illness: NONE
Preexisting Conditions: Hypoplastic left heart: s/p surgery. Reflux.
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: cc: itching all over, swollen lip, intense crying and very upset causing emesis. Exam: erythema, rash entire body, swollen lips, chest clear. No obvious stridor. Treatment: Orapred 2tsp given in office; Benadryl 1 tsp every 6-8hrs at home.


VAERS ID: 220132 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: New York  
Vaccinated:2004-05-01
Onset:2004-05-02
   Days after vaccination:1
Submitted: 2004-05-04
   Days after onset:2
Entered: 2004-05-11
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 602A2 / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1440 / 4 LL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0101N / 2 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Difficulty in walking, Erythema, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Left thigh red, swollen with difficulty walking 24hours after injection was given. Temp 98.9. Plus soft tissue swelling.


VAERS ID: 220135 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Alabama  
Vaccinated:2004-04-28
Onset:2004-04-28
   Days after vaccination:0
Submitted: 2004-04-28
   Days after onset:0
Entered: 2004-05-11
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1383AA / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0313 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0509N / 2 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Pruritus, Rash erythematous, Rash macular, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: AL0415

Write-up: Immunization at around 10.30AM. 4yo hiiponic female with presents within 40-50 minutes symptoms of itching and mom noted rash. Noted with erythematous macular. No difficulty of breathing, No edema noted. of review. N1 exam otherwise. Diagnosed urticaria.


VAERS ID: 220138 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Texas  
Vaccinated:2004-05-06
Onset:0000-00-00
Submitted: 2004-05-07
Entered: 2004-05-11
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1679AA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0950N / 2 RL / IM

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Pain, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: Seasonal allergies, no birth defects
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: L leg swollen, red, painful gave Benedryl and Motrin x 3days. Also warm compresses to thigh


VAERS ID: 220139 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-06
   Days after onset:2
Entered: 2004-05-11
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1606AA / 5 - / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0290 / 4 - / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0809N / 2 - / SC

Administered by: Private       Purchased by: Unknown
Symptoms: Cellulitis, Erythema, Feeling hot
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD Shot
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Given DTaP, IPV left arm on 5/3/04. Developed warmth, erythema by 5/5/04. Diagnosed cellulitis vs 122 rxn. Received Keflex x 10 days


VAERS ID: 220141 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Washington  
Vaccinated:2004-03-30
Onset:2004-03-31
   Days after vaccination:1
Submitted: 2004-04-01
   Days after onset:1
Entered: 2004-05-11
   Days after submission:39
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1625AA / UNK RA / -
HEPA: HEP A (HAVRIX) / SMITHKLINE BEECHAM T16A2 / UNK LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0554 / UNK RA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0807N / UNK LA / -

Administered by: Private       Purchased by: Unknown
Symptoms: Cellulitis, Erythema, Pain
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: WA042025

Write-up: Pain and redness right deltoid: diagnosed with cellulitis


VAERS ID: 220142 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Washington  
Vaccinated:2004-03-15
Onset:2004-03-18
   Days after vaccination:3
Submitted: 2004-04-14
   Days after onset:26
Entered: 2004-05-11
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1625AA / 4 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 RL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0807N / 2 RA / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 08219N / 1 LA / -

Administered by: Public       Purchased by: Public
Symptoms: Dyskinesia, Pyrexia, Upper respiratory tract infection
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dyskinesia (narrow), Noninfectious encephalopathy/delirium (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: WA042030

Write-up: Father states she felt warm 3 days after vaccine approximately. Had fever (face warm off and on -doing better today, but her hard jerks started at 1AM and dad noticed it in her sleep 1+ entire today. Otherwise sit, normal+ eating well today. First PC was 1.5-2.0 years ago. Taken to ER. Dr states viral respiratory illness. Will go to COH. 3-14-04: dad states she''s better. Did not go to Dr. Father states he doesn''t feel symptoms are vaccine related.


VAERS ID: 220147 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Maryland  
Vaccinated:2004-04-21
Onset:2004-04-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2004-05-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1697AA / 5 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Rash erythematous, Rash papular
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Small erythematous papular eruption bilateral temporal area also small area forehead.


VAERS ID: 220149 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Washington  
Vaccinated:2004-04-19
Onset:2004-04-19
   Days after vaccination:0
Submitted: 2004-04-23
   Days after onset:4
Entered: 2004-05-11
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1526AA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W07502 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0270N / 2 RA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Oedema
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 8cm redness and swelling left arm. Benadryl and cold compresses recommended.


VAERS ID: 220150 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Georgia  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-04
   Days after onset:0
Entered: 2004-05-11
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0711 / 4 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0959N / 2 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site oedema, Injection site pain
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Left leg 13.5 inch thigh, red, swollen, mildly tender at site of redness (RL-12 inch). Treatment: Tylenol, ice tonight, then apply heat.


VAERS ID: 220154 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-04-29
Onset:2004-04-30
   Days after vaccination:1
Submitted: 2004-05-01
   Days after onset:1
Entered: 2004-05-11
   Days after submission:10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1612AA / 5 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 LL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0662N / 2 RL / -

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Oedema
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD (AP), Lot # C1619AA, Left forearm, no previous doses;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Swelling, redness x6cm.


VAERS ID: 220156 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Missouri  
Vaccinated:2004-04-30
Onset:2004-05-01
   Days after vaccination:1
Submitted: 2004-05-03
   Days after onset:2
Entered: 2004-05-11
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 59089 / 5 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0146 / 4 RA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0948N / 2 LA / SC

Administered by: Private       Purchased by: Public
Symptoms: Injection site erythema, Injection site oedema, Injection site pain
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Onset of pain and significant swelling, redness in right upper arm on 05/01/04. Parent contacted physician instructed to use ice to area, Benadryl and pain reliever. Much improved in 36-48 hours. Rechecked 05/03/2004.


VAERS ID: 220157 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-04-28
Onset:0000-00-00
Submitted: 2004-04-30
Entered: 2004-05-11
   Days after submission:11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1612AA / 4 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0313 / 4 RA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0822N / 2 LA / SC

Administered by: Private       Purchased by: Public
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~DTaP (no brand name)~5~5.00~In Sibling|~DTaP (no brand name)~~0.00~In Sibling
Other Medications: UNK
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type:

Write-up: NONE


VAERS ID: 220158 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Illinois  
Vaccinated:2004-04-28
Onset:2004-04-29
   Days after vaccination:1
Submitted: 2004-05-03
   Days after onset:4
Entered: 2004-05-11
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 RA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1582 / 4 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Fatigue, Injection site reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Large local reaction in arm receiving DTAP within 24 hours. Local reaction vs. cellulitis. Treatment with Augmentin x 2 days, late development of tiredness.


VAERS ID: 220161 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Massachusetts  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 2004-05-05
Entered: 2004-05-11
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Private       Purchased by: Other
Symptoms: Drug ineffective, Infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~Varicella (no brand name)~1~8.00~In Sibling
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Undescended testicle and surgical repair;
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Mom called stating chicken pox going around in school and contracted a mild case of Varicella.


VAERS ID: 220163 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-04-19
Onset:2004-04-20
   Days after vaccination:1
Submitted: 2004-05-04
   Days after onset:14
Entered: 2004-05-11
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 630A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0148 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1297N / 2 RA / SC

Administered by: Public       Purchased by: Private
Symptoms: Injection site erythema, Injection site oedema
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Eczema;
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Mother states over telephone that left upper arm was swollen and red from shoulder to 1/2 way towards elbow. Noted on 04/20/04. Call received 04/23/04. Benadryl, Motrin, Ice to site ordered.


VAERS ID: 220166 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Tennessee  
Vaccinated:2004-05-04
Onset:2004-05-05
   Days after vaccination:1
Submitted: 2004-05-10
   Days after onset:5
Entered: 2004-05-11
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1614AA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X077N / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0960N / 2 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site pain, Injection site warmth
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 3 inch diameter erythema, tenderness on upper left thigh, also hot to the touch-onset was approximately 36 hours after vaccinations were given and lasted 3-4 days.


VAERS ID: 220181 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Georgia  
Vaccinated:2004-05-06
Onset:2004-05-07
   Days after vaccination:1
Submitted: 2004-05-11
   Days after onset:4
Entered: 2004-05-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U0856DA / 5 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1582 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. M1000 / 2 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Feeling hot
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE REPORTED
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Mother called. took child to ER Friday 5/7. C/o of right arm being red from shoulder to about 1" above elbow, warm to touch, and firm. She was instructed to use cool compresses and give child Benadryl. She said the arm is better now.


VAERS ID: 220192 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-02-23
Onset:2004-03-29
   Days after vaccination:35
Submitted: 2004-05-06
   Days after onset:37
Entered: 2004-05-12
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0337N / 1 LA / IM

Administered by: Private       Purchased by: Private
Symptoms: Petechiae, Platelet count decreased, Thrombocytopenic purpura
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Bronchiolitis 10/99
Allergies:
Diagnostic Lab Data: H/H 11.5/34.2; WBC 6.9; Platelet count 15,000; ESR 18; PT 11.8/PTT 29; PT INR 0.92; LDH 267; Uric acid 2.1
CDC Split Type:

Write-up: Developed ITP on 3/29/04 with diffuse petechial rash and platelet count of 15,000. Patient admitted for 1 day to hospital for IVIG therapy. Nurse follow up on 05/12/04: "None".


VAERS ID: 220194 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: New York  
Vaccinated:2004-04-19
Onset:2004-04-23
   Days after vaccination:4
Submitted: 2004-05-05
   Days after onset:12
Entered: 2004-05-12
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 RA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1033N / 2 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Arthralgia, Coordination abnormal, Guillain-Barre syndrome, Joint stiffness, Laboratory test abnormal, Pain, Tremor
SMQs:, Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Demyelination (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 76 days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: Inocent heart murmur; Tonsillar hypertrophy with snoring
Allergies:
Diagnostic Lab Data: Nerve conduction study ; EMG: abn;
CDC Split Type:

Write-up: About 4 days after receiving DTaP #5 and MMR #2, patient complained of bilateral knee pain, body shaking with heaving. Symptoms. Evaluated by doctor about 3 days later and found to have neck stiffness with position change, lower extremitiy areflexia, ataxia, shaking at rest when sitting. Diagnosed with GBS. Rx IVGG Nurse follow up on 06/17/04 states: "Pain." As Per annual follow up report: have not seen Pt or spoken to family since 08/04 as family has moved. (called mother 05/14/05 stated pt doing well) Recommend contacting family for follow up at new address.


VAERS ID: 220206 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Texas  
Vaccinated:2004-05-05
Onset:2004-05-05
   Days after vaccination:0
Submitted: 2004-05-07
   Days after onset:2
Entered: 2004-05-12
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U12570A / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0555 / 4 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0810N / 2 LA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~DTaP (no brand name)~5~4.00~In Patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Given Cephalexin: 250mg: tsp bidx 10days
CDC Split Type:

Write-up: Area is red on left outer leg and swollen. The reddened area is the size of a baseball.


VAERS ID: 220212 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Massachusetts  
Vaccinated:2004-05-04
Onset:2004-05-05
   Days after vaccination:1
Submitted: 2004-05-05
   Days after onset:0
Entered: 2004-05-12
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1273A / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X01462 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0612N / 2 RA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Swelling, Tenderness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Left upper arm with redness and ruber along entire length and half of circumference. Mild/mod swelling. Slightly tender to touch. Normal strength and movement.


VAERS ID: 220218 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: New York  
Vaccinated:2004-04-27
Onset:2004-04-27
   Days after vaccination:0
Submitted: 2004-04-29
   Days after onset:2
Entered: 2004-05-12
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1028BA / 5 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR U0557 / 4 RA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1125M / 2 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Feeling hot, Rash macular, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Child received immunizations as noted at clinic at bedtime that evening MOC noted that his right arm was very swollen, red and hot from neck to shoulder to elbow level. child was complaining of no pain and not dyspneic. On 4/28/04 she phoned his doctor with no response received; then clinic applied ice. No antihistamines . Given Motrin at bedtime. Condition improved on 4/29/04 with only blotchy redness noted in affected extremity.


VAERS ID: 220219 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-05
   Days after onset:1
Entered: 2004-05-12
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0707 / 4 RA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0955N / 2 RA / SC

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Feeling hot
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD Shot
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Red area measured : 12cm by 13cm . Warm to touch. Mom to use benadryl , cool compress.


VAERS ID: 220220 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-03-16
Onset:2004-03-17
   Days after vaccination:1
Submitted: 2004-04-15
   Days after onset:28
Entered: 2004-05-12
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1612AA / 5 RA / -
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0424N / 3 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0313 / 4 RA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0610N / 2 LA / -

Administered by: Private       Purchased by: Unknown
Symptoms: Cellulitis, Erythema, Pain, Pyrexia, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Keflex
Current Illness: NONE
Preexisting Conditions: Reactive airway disease, frequent resp. infection
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received immunizations on 3/16/04. DTaP+IPV in right arm. Next AM developed pain, swelling and redness and fever. Treated for possible cellulitis with Keflex.


VAERS ID: 220221 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Washington  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-05
   Days after onset:1
Entered: 2004-05-12
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U12720B / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X1233 / 4 RA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Oedema, Pain
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Left deltoid-edema+erythema from entire deltoid region: pt complained of arm pain. Afebrile, no systemic symptoms.


VAERS ID: 220222 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Washington  
Vaccinated:2004-05-05
Onset:2004-05-05
   Days after vaccination:0
Submitted: 2004-05-06
   Days after onset:1
Entered: 2004-05-12
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR C1625AA / UNK LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0555 / UNK LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0960N / UNK RA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Lethargy, Listless, Pyrexia, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Depression (excl suicide and self injury) (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Immunizations given at 3:30 pm 5/5/04 at 6pm. Fever, lethargy, listlessness, swelling to site of left arm. Slight redness. Fever to 104: called on call nurse service and on call doctor. Encouraged ER visit for flu: tylenol/motrin q 3hours: 5-6-04- continued fever 103 degrees, listlessness.


VAERS ID: 220226 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: North Carolina  
Vaccinated:2004-05-03
Onset:0000-00-00
Submitted: 2004-05-05
Entered: 2004-05-12
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1258BA / 5 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0148 / 3 RL / -
MMR: MEASLES + MUMPS + RUBELLA (VIRIVAC) / MERCK & CO. INC. 0809N / 2 LL / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Skin nodule, Type III immune complex mediated reaction
SMQs:, Anaphylactic reaction (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Looks like Arthus- type reaction to the tetanus component of the DTaP vaccine- area of induration/ erythema in right thigh 48 hours after vaccine.


VAERS ID: 220235 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Minnesota  
Vaccinated:2004-05-02
Onset:2004-05-02
   Days after vaccination:0
Submitted: 2004-05-04
   Days after onset:2
Entered: 2004-05-12
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 632A2 / 5 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 RL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0396N / 2 LL / SC

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cough, Lacrimation increased, Oedema, Rhinorrhoea, Urticaria
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Lacrimal disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Mild URI with a wheeze.
Preexisting Conditions: Triplegic cerebal palsy.
Allergies:
Diagnostic Lab Data: Pt. receives Botox injections every 3 months. Last one 3/24/04. Pt. was also give red popsicle after injections.
CDC Split Type:

Write-up: Mucous cough, swollen, watery eyes, clear nasal discharge hives back of neck and upper back. Pt. was checked by doctor. 0.15 ml epinephrine 1:1000 given subq. Benadryl 12.5 mg given IM. O2 sets 94-97%. Respirations 20. Pulse 160-120. Discharge to home with prescription for Prenisolone & oral Benadryl.


VAERS ID: 220241 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Arizona  
Vaccinated:2004-04-21
Onset:0000-00-00
Submitted: 2004-04-26
Entered: 2004-05-12
   Days after submission:16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1028AA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W065 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 081BN / 2 RL / SC

Administered by: Public       Purchased by: Other
Symptoms: Injection site erythema, Oedema
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: Undescended testicles.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Local erythema, edema 8 cm x 8 cm left arm.


VAERS ID: 220251 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Pennsylvania  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-11
   Days after onset:7
Entered: 2004-05-12
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 622A2 / 4 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0146 / 4 RA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0681N / 2 RA / SC

Administered by: Other       Purchased by: Other
Symptoms: Contusion, Erythema, Infection, Oedema, Skin nodule, Tenderness
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: History of Asthma.
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Received call from mother on 5/5/04. States 5/4 in am child right arm had small bruise, was pinkish red but not swollen. Later in the evening on 5/4/04, mother rechecked arm. Right arm had "fist" sized redness, swollen, tender to touch. Child had no fever, no drainage, no red streaks, and no decreased range of motion. Mother took child to ECU for evaluation. ECU stated arm was "infected" and placed child on Cephalexin. On 5/5 mother states redness and swelling are decreasing.


VAERS ID: 220254 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Illinois  
Vaccinated:2004-05-04
Onset:2004-05-05
   Days after vaccination:1
Submitted: 2004-05-10
   Days after onset:5
Entered: 2004-05-12
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 622A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1619 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0819N / 2 LL / SC

Administered by: Private       Purchased by: Public
Symptoms: Blister, Cellulitis, Erythema, Injection site reaction
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD Shot
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cellulitis to MMR site. 2 inch radius redness. Pin point blisters within this site. Pt complains of no pain to site.


VAERS ID: 220255 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-04-26
Onset:2004-04-27
   Days after vaccination:1
Submitted: 2004-04-29
   Days after onset:2
Entered: 2004-05-12
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 627A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0367 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0951N / 2 RA / SC

Administered by: Other       Purchased by: Public
Symptoms: Injection site reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD Shot
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: CA040025

Write-up: Lazy local reaction encompassing the entire deltoid area.


VAERS ID: 220258 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Maryland  
Vaccinated:2004-04-21
Onset:2004-04-30
   Days after vaccination:9
Submitted: 2004-05-12
   Days after onset:12
Entered: 2004-05-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 600A2 / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0367 / 4 RL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0138N / 2 RL / SC

Administered by: Military       Purchased by: Military
Symptoms: Chills, Lethargy, Oral intake reduced, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ibuprofen
Current Illness: None
Preexisting Conditions: PDDNOL (Pervasive developmental delay; autism spectrum)
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Reported by mother,who is an RN: Temp 103axillary w/ chills/fever despite ibuprofen; could not hold head up; refused all food and drink; unable to hold popsicle to mouth; very lethargic. Never had this reaction to a vaccine before.


VAERS ID: 220261 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-05-10
Onset:2004-05-11
   Days after vaccination:1
Submitted: 2004-05-12
   Days after onset:1
Entered: 2004-05-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0689N / 1 LA / SC

Administered by: Private       Purchased by: Private
Symptoms: Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tb test also done 5/10/2004
Current Illness:
Preexisting Conditions: Seasonal allergies
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had hives all over his body the following afternoon.


VAERS ID: 220281 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Florida  
Vaccinated:2004-05-05
Onset:2004-05-11
   Days after vaccination:6
Submitted: 2004-05-12
   Days after onset:1
Entered: 2004-05-13
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 5 - / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 4 - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / -

Administered by: Public       Purchased by: Public
Symptoms: Injection site erythema, Injection site swelling, Injection site warmth, Pyrexia, Sleep disorder
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: When child woke up had fever of 101, child slept for approximately 15 hours, arm where vaccine was received felt hot and there was redness from shoulder to elbow, it was raised, looked like he was burned with an iron. Child was also talking while sleeping, not common for him. Child taken to the doctor. They recommended Dimetap and to watch out for fever and bring him back by Friday however mother gave child Tylenol, Motrin and Benadryl instead. Redness has decreased.


VAERS ID: 220282 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-05-04
Onset:0000-00-00
Submitted: 2004-05-11
Entered: 2004-05-13
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 632B2 / 5 LL / IM
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0159P / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0906 / 4 RL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0131N / 2 RL / SC

Administered by: Private       Purchased by: Unknown
Symptoms: Erythema, Injection site induration, Injection site warmth
SMQs:, Anaphylactic reaction (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: red/hard/hot to touch / LVL


VAERS ID: 220285 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Wisconsin  
Vaccinated:2004-05-10
Onset:0000-00-00
Submitted: 2004-05-12
Entered: 2004-05-13
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 599C9 / 5 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 RL / -

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Swelling, Tenderness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Left thigh erythema and swelling with tenderness.


VAERS ID: 220297 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Alabama  
Vaccinated:2004-04-16
Onset:2004-04-17
   Days after vaccination:1
Submitted: 2004-04-27
   Days after onset:10
Entered: 2004-05-14
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1007AA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0313 / 4 RA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0132N / 1 RA / SC

Administered by: Public       Purchased by: Public
Symptoms: Cellulitis
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Otitis Media; URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: AL0416

Write-up: Cellulitis developed in right arm.


VAERS ID: 220313 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Alabama  
Vaccinated:2004-03-26
Onset:2004-03-27
   Days after vaccination:1
Submitted: 2004-03-29
   Days after onset:2
Entered: 2004-05-14
   Days after submission:45
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 630B2 / 5 RL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 5521A2 / 3 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR 8036N / 4 RA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0806N / 2 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Right thigh red and swollen area 16 cm x9.5cm, pt told by Dr to use ice and Benadryl


VAERS ID: 220314 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Washington  
Vaccinated:2004-04-02
Onset:2004-04-03
   Days after vaccination:1
Submitted: 2004-05-07
   Days after onset:33
Entered: 2004-05-14
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1625AA / 5 LA / -

Administered by: Private       Purchased by: Other
Symptoms: Erythema, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Mother called triage nurse. After shots were given, red and swollen. Next day-swelling from shoulder to elbow but feeling find. 04/02/04 shot given


VAERS ID: 220318 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Ohio  
Vaccinated:2004-05-04
Onset:2004-05-06
   Days after vaccination:2
Submitted: 2004-05-07
   Days after onset:1
Entered: 2004-05-14
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1697AA / 5 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X07711 / 4 RL / -

Administered by: Private       Purchased by: Unknown
Symptoms: Cellulitis
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Warts
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Left leg cellulitis. Keflex 250 mg/5 ml


VAERS ID: 220320 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-05-04
Onset:2004-05-06
   Days after vaccination:2
Submitted: 2004-05-07
   Days after onset:1
Entered: 2004-05-14
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 616A2 / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1233 / 4 RA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0171N / 2 RA / -

Administered by: Private       Purchased by: Other
Symptoms: Erythema, Injection site induration, Injection site warmth, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Local indurated, red , swollen, entire deltoid hot.


VAERS ID: 220348 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: California  
Vaccinated:2004-05-13
Onset:2004-05-14
   Days after vaccination:1
Submitted: 2004-05-15
   Days after onset:1
Entered: 2004-05-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 616A2 / 5 LA / IM
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0159P / 1 RA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1233 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0179N / 2 RA / SC

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site swelling
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Swelling and erythmea around injection site 24 hours after injection.


VAERS ID: 220355 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Ohio  
Vaccinated:2004-04-19
Onset:2004-04-28
   Days after vaccination:9
Submitted: 2004-05-04
   Days after onset:6
Entered: 2004-05-17
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 602A2 / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1002 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1235M / 2 RA / -

Administered by: Private       Purchased by: Private
Symptoms: Conjunctivitis, Dysuria, Pharyngitis, Pyrexia, Rash morbilliform, Vaccination complication, Vasculitis, Viral infection
SMQs:, Severe cutaneous adverse reactions (broad), Agranulocytosis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal infections (narrow), Vasculitis (narrow), Conjunctival disorders (narrow), Ocular infections (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Urine culture negative
CDC Split Type:

Write-up: 04/28/04: Dysuria, culture obtained, subsequently negative. 04/29/04: Fever 102.2, ill-appearing, morbilliform rash, pharyngitis, conjunctivitis, admitted to clinic to rule out Kawasaki Disease. Was seen by Infectious Disease specialist felt to be MMR reaction; symptoms resolved without treatment. Nurse follow up on 05/17/04 states: "Add: Viral syndrome."


VAERS ID: 220362 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Georgia  
Vaccinated:2004-04-14
Onset:2004-04-15
   Days after vaccination:1
Submitted: 2004-04-16
   Days after onset:1
Entered: 2004-05-17
   Days after submission:31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1028DA / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0148 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0682 / 2 RA / -

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Injection site warmth, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: GA04018

Write-up: 4/14/04: Received vaccine. 4/15/04: LD swollen and red: hot to touch. 4/14: Recommended warm compresses previously when received vaccine if arm swelled. 4/15: Recommended to see NC or MD : and please let nurse at health department know what MD recommends.


VAERS ID: 220365 (history)  
Form: Version 1.0  
Age: 4.5  
Gender: Female  
Location: North Carolina  
Vaccinated:2004-05-05
Onset:2004-05-07
   Days after vaccination:2
Submitted: 2004-05-08
   Days after onset:1
Entered: 2004-05-17
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1300BA / 5 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0148 / 4 LL / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0809N / 2 LA / SC

Administered by: Private       Purchased by: Public
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2x2 inch erythematous area left thigh: compresses.


VAERS ID: 220366 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-04-27
Onset:2004-04-27
   Days after vaccination:0
Submitted: 2004-04-29
   Days after onset:2
Entered: 2004-05-17
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1257AA / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0554 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0818 / 2 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Erythema, Feeling hot, Tenderness
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COUGH
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Redness, hot sensation, soreness x 2 days. Recommended cold compresses and tylenol.


VAERS ID: 220370 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Washington  
Vaccinated:2004-03-08
Onset:2004-03-09
   Days after vaccination:1
Submitted: 2004-03-10
   Days after onset:1
Entered: 2004-05-17
   Days after submission:67
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1612AA / 5 RA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0316 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0821N / 2 LA / -

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Feeling hot, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Redness/ swelling warm to right deltoid area. Pt seen by doctor. Treated with Benadryl 12.5mg, tylenol 160 mg/ 5ml.


VAERS ID: 220371 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: South Dakota  
Vaccinated:2001-03-16
Onset:2004-05-05
   Days after vaccination:1146
Submitted: 2004-05-07
   Days after onset:2
Entered: 2004-05-17
   Days after submission:10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1179K / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 477171 / 2 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0930K / 1 LL / SC

Administered by: Private       Purchased by: Public
Symptoms: Drug ineffective, Viral infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chicken pox diagnosed on 5-6-04 by doctor.


VAERS ID: 220372 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Oregon  
Vaccinated:2004-05-06
Onset:2004-05-08
   Days after vaccination:2
Submitted: 2004-05-10
   Days after onset:2
Entered: 2004-05-17
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U0997DA / 5 - / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1002 / 4 - / SC

Administered by: Private       Purchased by: Private
Symptoms: Inflammation, Injection site warmth, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Large welt on left thigh: given sq IPV. Hot to touch. Inflammation.


VAERS ID: 220373 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Ohio  
Vaccinated:2004-05-03
Onset:2004-05-04
   Days after vaccination:1
Submitted: 2004-05-06
   Days after onset:2
Entered: 2004-05-17
   Days after submission:11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR U1300CA / 5 LA / IM
HEPA: HEP A (HAVRIX) / SMITHKLINE BEECHAM 816A2 / 1 RA / IM

Administered by: Private       Purchased by: Private
Symptoms: Blister, Erythema, Injection site induration
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 10cm oval of erythema, rock hard induration covered with firm tiny vesicles around 1mm in size with several (1/2 cm vesicles): did not break down with pressure.


VAERS ID: 220385 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Arkansas  
Vaccinated:2004-05-12
Onset:2004-05-13
   Days after vaccination:1
Submitted: 2004-05-12
   Days after onset:1
Entered: 2004-05-17
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0711 / 4 RL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0951N / 2 LL / -

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site swelling, Injection site warmth
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: 3 inch diameter local red, raised, warm reaction.


VAERS ID: 220386 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: California  
Vaccinated:2004-05-04
Onset:2004-05-05
   Days after vaccination:1
Submitted: 2004-05-13
   Days after onset:8
Entered: 2004-05-17
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0368 / 4 LL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0100N / 2 RL / -

Administered by: Private       Purchased by: Public
Symptoms: Injection site erythema, Injection site oedema, Injection site pain, Injection site warmth, Pruritus
SMQs:, Anaphylactic reaction (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PPD (Parkedale, Lot # 00143P, right forearm, 2 previous doses); Tylenol; Trivilflor; Feosol;
Current Illness: Anemia;
Preexisting Conditions: Anemia;
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Redness and swollen on injection area. Also itchiness and warm to the touch. Approximately 6x7 inches. Pt had pain for 3 days.


VAERS ID: 220388 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Kansas  
Vaccinated:2004-05-10
Onset:2004-05-11
   Days after vaccination:1
Submitted: 2004-05-13
   Days after onset:2
Entered: 2004-05-17
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 601A2 / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W16182 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0393N / 2 RA / SC

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Face oedema, Nausea, Rash, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xoprenex PHN;
Current Illness: NONE
Preexisting Conditions: Asthma; Eczema; Allergies;
Allergies:
Diagnostic Lab Data: No labs;
CDC Split Type:

Write-up: Mom stated that around noon on 05/11/04, pt complained of feeling nauseous and then vomited. Mom states several hours later she noticed a fire red rash on pt''s legs (5-6pm). Mom states about 8pm they took pt to medical center ER because by then the pt''s eyes, cheeks, and ears had swelled up. The ER doctor diagnosed pt with an allergic reaction and gave pt Benadryl and Liquid steroids. Mom reports when she called me on 05/12/04 that decreased swelling, decreased rash, pt much better the next day. ER doctor could not confirm that this event was related to the vaccinations.


VAERS ID: 220392 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Mississippi  
Vaccinated:2004-05-03
Onset:2004-05-05
   Days after vaccination:2
Submitted: 2004-05-05
   Days after onset:0
Entered: 2004-05-17
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 622A2 / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1582 / 4 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Feeling hot, Hyperhidrosis, Injection site erythema, Pruritus, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data: none
CDC Split Type: MS04011

Write-up: Client in today with Grandmother for swelling lt Deltoid. Warm to touch and facila sweating no fever reported. Symptoms started 5/5/04 at 9am redness to site itching


VAERS ID: 220404 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Unknown  
Location: California  
Vaccinated:2004-04-27
Onset:2004-04-27
   Days after vaccination:0
Submitted: 2004-05-17
   Days after onset:20
Entered: 2004-05-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1697AAA / 5 LA / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR XO707 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1297N / 2 RA / SC

Administered by: Private       Purchased by: Private
Symptoms: Injection site erythema, Injection site swelling, Injection site warmth
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PATANOL
Current Illness: ALLERGIC CONJUNCTIVITIS
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: PT. RECEIVED DapTCELL VACCINE IN L. DELTOID. AFTER 48 HRS., PT RETURNED TO OFFICE TO HAVE PPD READ & PARENT STATED INJ. SITE OF DapTCELL BECAME RED, SWOLLEN, & WARM TO THE TOUCH. ON EXAM, ARM WAS NO LONGER SWOLLEN, ONLY SLIGHTLY PINK, NOT PAINFUL OR WARM TO TOUCH.THIS WAS 1ST./ DOSE WITH DAPTACEL-PREVIOUS IMM.WITH TRIPEDIA.


VAERS ID: 220432 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Iowa  
Vaccinated:2004-04-23
Onset:2004-04-23
   Days after vaccination:0
Submitted: 2004-04-28
   Days after onset:5
Entered: 2004-05-18
   Days after submission:20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR C1606AA / 5 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W0907 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0746N / 2 RA / -

Administered by: Public       Purchased by: Public
Symptoms: Erythema, Feeling hot, Swelling, Tenderness, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Zyrtex
Current Illness: NONE
Preexisting Conditions: Allergy
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: ia04007

Write-up: Severe hives 45 minutes after shot given: arm was triple the size for 4-5 days, red, hot and very tender.


VAERS ID: 220434 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Alaska  
Vaccinated:2004-04-07
Onset:2004-04-09
   Days after vaccination:2
Submitted: 2004-04-12
   Days after onset:3
Entered: 2004-05-18
   Days after submission:36
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 616A2 / 5 LA / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR W1619 / 4 LA / SC
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1008M / 2 RA / SC

Administered by: Public       Purchased by: Public
Symptoms: Contusion, Erythema, Pain, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: AK20415

Write-up: Redness, pain, swelling left upper arm beginning 4-9-04. Slightly bruised looking today 4-12, otherwise normal.


VAERS ID: 220438 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Florida  
Vaccinated:2004-05-10
Onset:2004-05-11
   Days after vaccination:1
Submitted: 2004-05-12
   Days after onset:1
Entered: 2004-05-18
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1027AA / 5 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0146 / 4 LL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0950N / 2 LA / -

Administered by: Private       Purchased by: Public
Symptoms: Erythema, Injection site swelling, Injection site warmth
SMQs:, Anaphylactic reaction (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Red, raised, feverish area around injection site approximately 8cm in diameter. Non tender.


VAERS ID: 220440 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Nebraska  
Vaccinated:2004-05-10
Onset:2004-05-11
   Days after vaccination:1
Submitted: 2004-05-12
   Days after onset:1
Entered: 2004-05-18
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0955N / 2 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Erythema, Pyrexia, Tenderness
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: Coughx 2 weeks
Preexisting Conditions: Hemophilia A: Allergy PCN and Sulfa
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Vaccine given 5/10/04 to 4 year old with hemophilia A. Ice packed. Developed erythema, tenderness and fever to 102 degrees.


VAERS ID: 220446 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Missouri  
Vaccinated:2004-04-29
Onset:2004-04-30
   Days after vaccination:1
Submitted: 2004-05-03
   Days after onset:3
Entered: 2004-05-18
   Days after submission:15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C1696AA / 5 RL / IM
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0882N / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR X0711 / 4 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 089N / 2 LL / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Turner''s syndrome
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Mild redness aterolateral right thigh.


VAERS ID: 220452 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Oregon  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 2004-05-10
Entered: 2004-05-18
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / SANOFI PASTEUR U1288DA / 5 LA / -

Administered by: Private       Purchased by: Private
Symptoms: Injection site induration, Injection site oedema
SMQs:, Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Local reaction-swelling/induration of 4.5x6cm on arm. Swelling almost gone by 05/10/04.


VAERS ID: 220516 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Unknown  
Vaccinated:2003-02-12
Onset:2003-02-15
   Days after vaccination:3
Submitted: 2004-05-14
   Days after onset:453
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0868M / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Injection site rash, Rash vesicular
SMQs:, Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0303USA02761

Write-up: Information has been received from a registered nurse RN concerning a 4 year old male who on 12FEB2003 was vaccinated with a dose of varicella virus vaccine live (lot 643593/0868M). The RN reported that on 15FEB2003, the patient developed several vesicular lesions at the injection site. Unspecified medical attention was sought. At the time of this report, the outcome was unknown. The RN also reported that the patient''s 7 month old sibling also developed vesicular lesions after being exposed to the brother''s vesicular lesions (WAES0303ISA002901). Additional information has been requested.


VAERS ID: 220531 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Texas  
Vaccinated:1999-07-12
Onset:2003-04-02
   Days after vaccination:1360
Submitted: 2004-05-14
   Days after onset:407
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 630674/0423J / 1 - / SC

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Infection, Pyrexia, Skin ulcer
SMQs:, Lack of efficacy/effect (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Body temp 04/02/03 101 F.
CDC Split Type: WAES0304USA00247

Write-up: Information has been received from a licensed visiting nurse concerning a 4 year old female patient with no allergies and no past medical history who on 12-Jul-1999 was vaccinated subcutaneously in the left anterior thigh with a first dose of varicella virus vaccine live (Lot #630574/0423J). There was no illness at the time of vaccination. On 02-Apr-2003, the patient was diagnosed with chicken pox. On day 1, the patient had more than 100 varicella lesions covering her body, scalp and in her ears. The patient had a low grade fever of 101 F. Unspecified medical attention was sought, but no other diagnostic tests were performed. On 08-Apr-2003 , the patient recovered. Additional information is not expected.


VAERS ID: 220538 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: New Jersey  
Vaccinated:1999-08-13
Onset:2003-03-29
   Days after vaccination:1324
Submitted: 2004-05-14
   Days after onset:411
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS - / 3 - / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / 1 - / SC

Administered by: Private       Purchased by: Private
Symptoms: Blister, Rash macular, Skin ulcer
SMQs:, Severe cutaneous adverse reactions (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: body height measurement 39 inches, body weight measurement 08/13/98 7 lb 3 oz birth weight. body weight measurement 34 lb.
CDC Split Type: WAES0304USA00479

Write-up: Information has been received from a registered nurse concerning a "well" 4-year-old white female with no medical history or allergies who on 13-Aug-1999 was vaccinated SC in the left arm with a first dose of varicella virus vaccine live (lot #0450J- invalid). Concomitant vaccination the same day included a third dose IM in the right arm of hepatitis B vaccine. recombinant (Engerix-B) (lot # 2941A2). The reporter indicated that in the a.m. of 29-Mar-2003 the patient developed scattered macules, vesicles and scabbed lesions on the arms, face and trunk. A doctor''s visit was required. Calamine treatment was provided. Subsequently, the patient recovered. There were no diagnostic tests or laboratory results. It was unknown if the patient or her sibling had any adverse events following prior vaccinations.


VAERS ID: 220552 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Missouri  
Vaccinated:2003-03-24
Onset:2003-03-25
   Days after vaccination:1
Submitted: 2004-05-14
   Days after onset:415
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 6435860802M / UNK - / -

Administered by: Private       Purchased by: Private
Symptoms: Drug ineffective, Infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: WAES0304USA00898

Write-up: Information has been received from a physician concerning a 4 year old male patient with no preexisiting medical conditions, who on 24Mar2003 was vaccinated with a dose varicella virus vaccine live. The physician reported that the next morning, 25Mar2003, the patient presented to the physician''s office at 08:00AM with vesicular chicken pox, about "8-10 lesions" on his abdomen and a few under each arm (physician also reported as developed full blown chicken pox greater than 25 lesions in approximately 15 hours). The physician reported there was no known exposure to another case. It was noted the patient recovered. The reporter noted the patient did not have a fever. It was also noted the patient was not ill at the time of vaccination, and there were no laboratory tests performed. No further information is expected.


VAERS ID: 220561 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Minnesota  
Vaccinated:1999-12-13
Onset:2003-03-31
   Days after vaccination:1204
Submitted: 2004-05-14
   Days after onset:409
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DPP: DIPHTHERIA TOXOID + PERTUSSIS + IPV (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Private       Purchased by: Other
Symptoms: Drug ineffective, Infection, Rash papular
SMQs:, Lack of efficacy/effect (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~Varicella (Varivax)~~5.00~In Sibling
Other Medications:
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: body height measurement, 03/31/03, 32 inches body weight measurement, 03/31/03, 30.5 pound
CDC Split Type: WAES0304USA01221

Write-up: Information has been received from a registered nurse concerning a 4 year old female with no past medical history and no known drug allergies who on 13Dec1999 was vaccinated with a dose of varicella virus vaccine live. There was no illness at the time of vaccination. Concomitant therapy that day included a dose of diphtheria toxoid (+) pertussis vaccine (+) tetanus toxoid. In approximately March, 2003, "over the last month or so", the patient developed a mild case of chickenpox. Unspecified medical attention was sought. Follow up information indicated that on 31Mar2003 the patient broke out in a papilovesicular rash on her chest, arms, back, and face. The reporter indicated that her older sister had a similar breakout 1 week prior that was determined to be chickenpox. The outcome was reported as recovered. The nurse also reported that two other siblings developed an allergic reaction to amoxicillin and an ear infection, previously reported as chickenpox and general malaise and developed a mild case of chickenpox and "strep throat". No further information is expected.


VAERS ID: 220575 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Maryland  
Vaccinated:1999-11-01
Onset:2003-04-10
   Days after vaccination:1256
Submitted: 2004-05-14
   Days after onset:400
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / 1 - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Infection, Pruritus
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~Varicella (Varivax)~~2.00~In Sibling
Other Medications: UNK
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type: WAES0304USA01501

Write-up: Information has been received from a certified medical assistant concerning a 4 year old white female, also reported as an adolescent, with no past medical history and no known drug allergies who on 11/1/99 was vaccinated in the leg with a first dose of varicella virus vaccine live (lot C7165). There was no illness at the time of vaccination. On 4/10/03 the patient presented to the doctor''s office with a moderate case of chicken pox. Unspecified medical attention was sought. Follow up information that on 4/10/03 the patient was seen in the office with complaints of itching on her arms, legs, and stomach with small pustules. The child was recently exposed to another child with varicella. The child was diagnosed with varicella. The outcome was reported as recovered. The reporter indicated that the patient''s sister was vaccinated with a dose of varicella virus vaccine live and developed a moderate case of chickenpox. No further information is expected.


VAERS ID: 220583 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Texas  
Vaccinated:2000-04-10
Onset:2003-04-15
   Days after vaccination:1100
Submitted: 2004-05-14
   Days after onset:395
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1727J / 1 - / SC

Administered by: Private       Purchased by: Private
Symptoms: Drug ineffective, Infection, Pruritus, Skin ulcer
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Body height: 42 inches; Body weight 53.5 lbs.
CDC Split Type: WAES0304USA01717

Write-up: Information has been received from a licensed vocational nurse concerning a 4 year old white female with no medical history and no allergies who on 4/10/00 was vaccinated SC in the left thigh with a first dose of varicella virus vaccine live (lot # 632717/1727J). There was no illness at the time of vaccination. Neither the patient nor her sibling developed adverse events following prior vaccinations. On 4/15/03 the patient came into the office with itching and a chicken pox rash with over 100 lesions with at least 50 lesions on one thigh. Some of the lesions were circled with a red ring about 1/4 inch from the center making the lesions about the size of a nickel to a quarter. It was reported on 4/16/03 that this was only day 2 and the patient is currently getting more. It was noted that this was an office visit confirmation and that there were no diagnostic or laboratory tests performed. Subsequently, the patient recovered. No further information is expected.


VAERS ID: 220585 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 2004-05-14
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type: WAES0304USA01777

Write-up: Information has been received from a physician concerning a 4 year old male who was vaccinated with a dose of varicella virus vaccine live (date not reported). The reporter stated the patient has experienced 2 break through case of chicken pox. It was noted the cases were considered mild. It was noted that there were no details provided on the cases. Unspecified medical attention was sought. Additional information has been requested.


VAERS ID: 220617 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: West Virginia  
Vaccinated:2000-04-28
Onset:2003-04-27
   Days after vaccination:1094
Submitted: 2004-05-14
   Days after onset:383
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. - / 3 - / -
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0087K / 1 - / -

Administered by: Private       Purchased by: Private
Symptoms: Drug ineffective, Rash vesicular, Viral infection
SMQs:, Lack of efficacy/effect (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Dermatitis contact
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type: WAES0304USA02758

Write-up: Information has been received from a certified medical assistant concerning a 4 year old male patient with a history of contact dermatitis at 18 months of agae who on 28APR2000 was vaccinated in the left arm with a first dose of varicella virus vaccine live (lot no. 632724/0087K). concomitant vaccination in the left leg included a third doe of hepatitis B virus vaccine rHBsAg (yeast) (manufacturer unknown) (Lot 1317K). There was no illness at the time of vaccination. On 27APR2003, the patient developed "typical" chickenpox. The patient presented to the doctor''s office with approximately 20 widely disseminated vesicular lesions, but no treatment was required. Subsequently, the patient recovered. Additional information is not expected.


VAERS ID: 220622 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: New Hampshire  
Vaccinated:2000-09-01
Onset:0000-00-00
Submitted: 2004-05-14
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 6348500762K / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Infection, Rash
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type: WAES0304USA02784

Write-up: Information has been received from a licensed practical nurse (LPN) concerning a 4 year old female who on 01Sep2000, was vaccinated with a dose of varicella virus vaccine live. The LPN reported that in April 2003 the pt presented to the physician''s office with a rash. The pt had approx. 25-50 lesions on her turso and buttocks. A diagnosis of chickenpox was made. At the time of this report, the outcome was unknown. Additional information has been requested.


VAERS ID: 220645 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Unknown  
Vaccinated:2000-05-30
Onset:2003-03-17
   Days after vaccination:1021
Submitted: 2004-05-14
   Days after onset:423
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0305USA00585

Write-up: Information has been received from a health professional concerning a 4 year old female who on 30-May-2000 was vaccinated with a dose of varicella virus vaccine live. On 17-Mar-2003 the patient developed break-through chickenpox. It was unknown if medical attention was sought. No product quality complaint was noted. It was also noted that 12 other patients were vaccinated with a dose of varicella virus vaccine live and developed break-through chickenpox (WAES #0305USA00356, 0304USA00584, 0305USA00586 through 0305USA00595). Additional information has been requested.


VAERS ID: 220646 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Male  
Location: Unknown  
Vaccinated:1999-09-09
Onset:2003-04-11
   Days after vaccination:1310
Submitted: 2004-05-14
   Days after onset:399
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Viral infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0305USA00586

Write-up: Information has been received from a health professional concerning a 4 year old male on 09SEP1999 was vaccinated with a dose of varicella virus vaccine live. On 11APR2003 the patient developed break through chickenpox. It was unknown if medical attention was sought. No product quality complaint was noted. It was also noted that 12 other patients were vaccinated with a dose of varicella virus vaccine live and developed break through chickenpox. Additional information has been requested.


VAERS ID: 220648 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Unknown  
Vaccinated:2002-02-09
Onset:2003-02-24
   Days after vaccination:380
Submitted: 2004-05-14
   Days after onset:444
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Drug ineffective, Viral infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0305USA00588

Write-up: Information has been received from a health professional concerning a 4 year old female who on 09-FEB2002 was vaccinated with a dose of varicella virus vaccine live. On 24FEB2003 the patient developed break through chickenpox. It was unknown if medical attention was sought. No product quality complaint was noted. It was also noted that 12 other patients were vaccinated with a dose of varicella virus vaccine live and developed break through chickenpox. Additional information has been requested.


VAERS ID: 220649 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Unknown  
Location: Unknown  
Vaccinated:2001-05-21
Onset:2003-03-03
   Days after vaccination:651
Submitted: 2004-05-14
   Days after onset:437
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Viral infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions: UNK
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0305USA00589

Write-up: Information has been received from a health professional concerning a 4 year old patient who on 21MAY2001 was vaccinated with a dose of varicella virus vaccine live. On 03MAR2003 the patient developed break through chickenpox. It was unknown if medical attention was sought. No product quality complaint was noted. It was also noted that 12 other patients received a dose of varicella virus vaccine live and developed break through chickenpox. Additional information has been requested.


VAERS ID: 220655 (history)  
Form: Version 1.0  
Age: 4.0  
Gender: Female  
Location: Unknown  
Vaccinated:1999-02-02
Onset:2003-02-04
   Days after vaccination:1463
Submitted: 2004-05-14
   Days after onset:464
Entered: 2004-05-18
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Drug ineffective, Viral infection
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0305USA00595

Write-up: Information has been received from a health professional concerning an 8 year old female who on 02FEB1999 was vaccinated with a dose of varicella virus vaccine live. On 04 FEB 2003 the patient developed break through chickenpox. It was unknown if medical attention was sought. No product quality complaint was noted. It was also noted that 12 other patients were vaccinated with a dose of varicella virus vaccine live and developed break through chickenpox. Additional information has been requested.


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