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This is VAERS ID 105871

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 105871
VAERS Form:
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 812A2 / 0 LL / -
HEP: ENGERIX-B / SMITHKLINE 2405A2 / 1 RL / -
HIBV: HIBTITER / LEDERLE(PRAXIS) M035PE / 0 RL / -
IPV: IPV / MERIEUX INST M0938 / 0 LL / SC

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 12/8/2009

VAERS ID: 105871 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-30 1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 812A2 / 0 LL / -
HEP: ENGERIX-B HEP B (ENGERIX-B) / SMITHKLINE SMITHKLINE BEECHAM 2405A2 / 1 RL / -
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M035PE / 0 RL / -
IPV: IPV POLIO VIRUS, INACT. (NO BRAND NAME) / MERIEUX INST PASTEUR MERIEUX INST. M0938 / 0 LL / SC

Administered by: Private      Purchased by: Unknown Private
Symptoms: SIDS, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 5/14/2017

VAERS ID: 105871 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 0 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 1 RL / -
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M035PE / 0 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 0 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 9/14/2017

VAERS ID: 105871 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 0 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 1 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 0 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 0 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 2/14/2018

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 6/14/2018

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 8/14/2018

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 9/14/2018

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 10/14/2018

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 12/24/2020

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 12/30/2020

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 5/7/2021

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS


Changed on 5/21/2021

VAERS ID: 105871 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Oregon
Vaccinated:1997-10-06
Onset:1997-11-24
Submitted:1997-12-12
Entered:1997-12-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 812A2 / 1 LL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2405A2 / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M035PE / 1 RL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0938 / 1 LL / SC

Administered by: Private      Purchased by: Private
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NONE-SIDS

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