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This is VAERS ID 119248

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 119248
VAERS Form:
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 457788 / 0 LL / IM
HEP: RECOMBIVAX HB / MSD 1190H / 0 RL / IM
HIBV: PEDVAXHIB / MSD 110211 / 0 RL / IM
IPV: POLIOVAX / CONNAUGHT LTD N0726 / 0 LL / SC
RV: ROTASHIELD / WYETH 1190H / 0 RL / IM

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS, INFECT, NO DRUG EFFECT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 12/8/2009

VAERS ID: 119248 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-25 1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 457788 / 0 LL / IM
HEP: RECOMBIVAX HB HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 1190H / 0 RL / IM
HIBV: PEDVAXHIB HIB (PEDVAXHIB) / MSD MERCK & CO. INC. 110211 / 0 RL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N0726 / 0 LL / SC
RV: ROTASHIELD ROTAVIRUS (ROTASHIELD) / WYETH WYETH PHARMACEUTICALS, INC 1190H / 0 RL / IM

Administered by: Private      Purchased by: Unknown Public
Symptoms: Drug ineffective, Infection, SIDS, Sudden infant death syndrome, INFECT, NO DRUG EFFECT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 8/31/2010

VAERS ID: 119248 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES 457788 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 0 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 0 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 1190H / 0 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 5/14/2017

VAERS ID: 119248 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 457788 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 0 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 0 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 0 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 9/14/2017

VAERS ID: 119248 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 0 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 0 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 0 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 0 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 2/14/2018

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 6/14/2018

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 8/14/2018

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 9/14/2018

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 10/14/2018

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 12/24/2020

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 12/30/2020

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 5/7/2021

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;


Changed on 5/21/2021

VAERS ID: 119248 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Missouri
Vaccinated:1999-02-12
Onset:1999-02-14
Submitted:1999-02-17
Entered:1999-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1190H / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 110211 / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0726 / 1 LL / SC
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 1190H / 1 RL / IM

Administered by: Private      Purchased by: Public
Symptoms: Drug ineffective, Infection, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-14
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:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: pericardial draw post mortem-blood cult grew type B H flu
CDC 'Split Type':

Write-up: DOA in hosp ER 14FEB99;blood cult grew H. flu type B;

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