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This is VAERS ID 105621

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 105621
VAERS Form:
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: UNK. DTAP / UNCLASSIFIED 6C81349 / 1 RL / -
HIBV: UNK. HAEMOPHILUS B / UNCLASSIFIED M195RF / 1 LL / -
IPV: UNK. IPV / UNCLASSIFIED M0843 / 1 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: SIDS, HYPOTENS, APNEA, ACIDOSIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 12/8/2009

VAERS ID: 105621 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-15 1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: UNK. DTAP DTAP (NO BRAND NAME) / UNCLASSIFIED UNKNOWN MANUFACTURER 6C81349 / 1 RL / -
HIBV: UNK. HAEMOPHILUS B HIB (NO BRAND NAME) / UNCLASSIFIED UNKNOWN MANUFACTURER M195RF / 1 LL / -
IPV: UNK. IPV POLIO VIRUS, INACT. (NO BRAND NAME) / UNCLASSIFIED UNKNOWN MANUFACTURER M0843 / 1 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, SIDS, Sudden infant death syndrome, HYPOTENS, APNEA, ACIDOSIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 5/14/2017

VAERS ID: 105621 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 1 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 1 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 1 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 9/14/2017

VAERS ID: 105621 Before After
VAERS Form:(blank) 1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 1 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 1 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 1 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 2/14/2018

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 6/14/2018

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 8/14/2018

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 9/14/2018

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 10/14/2018

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 12/24/2020

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 12/30/2020

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 5/7/2021

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


Changed on 5/21/2021

VAERS ID: 105621 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Kentucky
Vaccinated:1997-11-10
Onset:1997-11-10
Submitted:1997-11-11
Entered:1997-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public      Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;

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