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This is VAERS ID 122135

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 122135
VAERS Form:
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 457788 / 0 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) 410303A / 0 RL / IM
IPV: POLIOVAX / CONNAUGHT LTD P0400 / 0 LL / -
RV: ROTASHIELD / WYETH 4988075 / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 12/8/2009

VAERS ID: 122135 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-17 1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 457788 / 0 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS 410303A / 0 RL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. P0400 / 0 LL / -
RV: ROTASHIELD ROTAVIRUS (ROTASHIELD) / WYETH WYETH PHARMACEUTICALS, INC 4988075 / 0 - / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 8/31/2010

VAERS ID: 122135 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES 457788 / 0 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS 410303A / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 0 LL / -
RV: ROTAVIRUS (ROTASHIELD) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 4988075 / 0 - / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 5/14/2017

VAERS ID: 122135 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 457788 / 0 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH 410303A / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 0 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 0 - / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 9/14/2017

VAERS ID: 122135 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 0 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 0 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 0 1 - MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 2/14/2018

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 6/14/2018

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 8/14/2018

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 9/14/2018

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 10/14/2018

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 12/24/2020

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 12/30/2020

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 5/7/2021

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;


Changed on 5/21/2021

VAERS ID: 122135 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Ohio
Vaccinated:1999-04-21
Onset:1999-04-22
Submitted:1999-05-03
Entered:1999-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 457788 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 410303A / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. P0400 / 1 LL / -
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH 4988075 / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-04-22
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: NONE
Preexisting Conditions: prematurity
Allergies:
Diagnostic Lab Data: autopsy
CDC 'Split Type':

Write-up: sudden infant death w/in 24hr;autopsy was nl;

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=122135&WAYBACKHISTORY=ON


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