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This is VAERS ID 128300

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 128300
VAERS Form:
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPH: TETRAMUNE / LEDERLE - / 0 - / IM
HEP: UNK. HEPATITIS B / UNCLASSIFIED - / 0 - / -
OPV: ORIMUNE / LEDERLE - / 0 - / PO
RV: ROTASHIELD / WYETH - / 0 - / PO

Administered by: ??      Purchased by: Unknown
Symptoms: CYANOSIS, INFECT, RHINITIS, APNEA, INFECT URIN TRACT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type':

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydrone"phrosis, ureteral stenosis,


Changed on 12/8/2009

VAERS ID: 128300 Before After
VAERS Form:
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-21 1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPH: TETRAMUNE / LEDERLE - / 0 - / IM
DTPHIB: DTP + HIB (TETRAMUNE) / LEDERLE LABORATORIES - / 0 - / IM
HEP: UNK. HEPATITIS B HEP B (NO BRAND NAME) / UNCLASSIFIED UNKNOWN MANUFACTURER - / 0 - / -
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES - / 0 - / PO
RV: ROTASHIELD ROTAVIRUS (ROTASHIELD) / WYETH WYETH PHARMACEUTICALS, INC - / 0 - / PO

Administered by: ??      Purchased by: Unknown (blank)
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection, CYANOSIS, INFECT, RHINITIS, APNEA, INFECT URIN TRACT

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': (blank) 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydrone"phrosis, hydronephrosis, ureteral stenosis, .


Changed on 8/31/2010

VAERS ID: 128300 Before After
VAERS Form:
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / LEDERLE LABORATORIES - / 0 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 0 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES - / 0 - / PO
RV: ROTAVIRUS (ROTASHIELD) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH - / 0 - / PO

Administered by: ??      Purchased by: ??
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis, .


Changed on 5/14/2017

VAERS ID: 128300 Before After
VAERS Form:
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / LEDERLE LABORATORIES PFIZER/WYETH - / 0 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 0 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH - / 0 - / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 0 - / PO

Administered by: (blank) Private      Purchased by: (blank) Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis, .


Changed on 9/14/2017

VAERS ID: 128300 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 0 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 0 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 0 1 - MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 0 1 - MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 2/14/2018

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 6/14/2018

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 8/14/2018

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 9/14/2018

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 10/14/2018

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 12/24/2020

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 12/30/2020

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 5/7/2021

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,


Changed on 5/21/2021

VAERS ID: 128300 Before After
VAERS Form:1
Age:0.2
Sex:Unknown
Location:New York
Vaccinated:1999-07-08
Onset:1999-08-31
Submitted:1999-09-01
Entered:1999-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH - / 1 - / IM
HEP: HEP B (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO
RV: ROTAVIRUS (ROTASHIELD) / PFIZER/WYETH - / 1 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Apnoea, Cyanosis, Infection, Rhinitis, Skin discolouration, Urinary tract infection

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1999-08-31
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: preemie 34 wk gest w/ vesicostomy d/t urethral obstuction; Apgar 5-7, , hypotension, hyperbilirubinemia to 9 @ birth, intubated d/t abd ascites x3 day then infrequent apnea, bradycardia; cystocopy 8/99, bilateral ureteral stenosis
Allergies:
Diagnostic Lab Data: unkown
CDC 'Split Type': 899245020A

Write-up: p/vax pt devel congestion & a runny nose; seen by MD who observed pt to be mottled; pale & cyanotic; pt taken to ER & was intubated; attempts at resuscitation unsuccessful; Autopsy revealed urosepsis with E coli bacteria, pyelonephritis, cystitis, hydronephrosis, ureteral stenosis,

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