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This is VAERS ID 120597

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 120597
VAERS Form:
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 858A2 / 1 RL / IM
HIBV: PEDVAXHIB / MSD 0003H / 1 LL / IM
IPV: POLIOVAX / CONNAUGHT LTD N0699 / 1 LL / IM

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS, AGITATION, FEVER, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type': NONE

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 12/8/2009

VAERS ID: 120597 Before After
VAERS Form:
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-31 1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 858A2 / 1 RL / IM
HIBV: PEDVAXHIB HIB (PEDVAXHIB) / MSD MERCK & CO. INC. 0003H / 1 LL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N0699 / 1 LL / IM

Administered by: Private      Purchased by: Unknown Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, SIDS, Sudden infant death syndrome, Unevaluable event, AGITATION, FEVER, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type': NONE (blank)

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 5/14/2017

VAERS ID: 120597 Before After
VAERS Form:
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 1 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 9/14/2017

VAERS ID: 120597 Before After
VAERS Form:(blank) 1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 1 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 1 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 2/14/2018

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 6/14/2018

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 8/14/2018

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 9/14/2018

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 10/14/2018

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 12/24/2020

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 12/30/2020

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 5/7/2021

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;


Changed on 5/21/2021

VAERS ID: 120597 Before After
VAERS Form:1
Age:0.4
Sex:Female
Location:California
Vaccinated:1999-02-18
Onset:1999-02-21
Submitted:1999-03-19
Entered:1999-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 858A2 / 2 RL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0003H / 2 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 2 LL / IM

Administered by: Private      Purchased by: Other
Symptoms: Agitation, Apnoea, Cardiac arrest, Pyrexia, Sudden infant death syndrome, Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-02-21
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy performed-results unavailable @ this time;
CDC 'Split Type':

Write-up: pt found by parent not breathing, CPR started, transported to nearest ER on 21FEB99, unable to resuscitate;

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