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This is VAERS ID 121007

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 121007
VAERS Form:
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 888A2 / 0 RL / -
HEP: RECOMBIVAX HB / MSD 1394H / 1 LL / -
HIBV: ACT-HIB / CONNAUGHT LABS 0998890 / 0 LL / -
IPV: POLIOVAX / CONNAUGHT LTD N0699 / 0 RL / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': NONE

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 12/8/2009

VAERS ID: 121007 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-08 1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 888A2 / 0 RL / -
HEP: RECOMBIVAX HB HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 1394H / 1 LL / -
HIBV: ACT-HIB HIB (ACTHIB) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0998890 / 0 LL / -
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N0699 / 0 RL / -

Administered by: Private      Purchased by: Unknown Public
Symptoms: Agitation, Apnoea, Cardiac arrest, SIDS, Stupor, Sudden infant death syndrome, AGITATION, STUPOR, APNEA, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': NONE (blank)

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 5/14/2017

VAERS ID: 121007 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 0 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 1 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 0 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 0 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 9/14/2017

VAERS ID: 121007 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 0 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 1 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 0 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 0 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 2/14/2018

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 6/14/2018

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 8/14/2018

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 9/14/2018

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 10/14/2018

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 12/24/2020

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 12/30/2020

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 5/7/2021

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;


Changed on 5/21/2021

VAERS ID: 121007 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:Michigan
Vaccinated:1999-03-30
Onset:1999-04-01
Submitted:1999-04-06
Entered:1999-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 888A2 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1394H / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 0998890 / 1 LL / -
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0699 / 1 RL / -

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Stupor, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-01
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: NA
Current Illness: diaper rash
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt was given last feeding @ 4AM, smiling & doing well;found in crib @ 7AM unresponsive;CPR started & taken to hosp, unsuccessful in resuscitation;mom states pt cranky 31MAR when someone touched where immun given;

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