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This is VAERS ID 158472

History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 158472
VAERS Form:
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 1 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 1 - / IM

Administered by: Other      Purchased by: Other
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 2/14/2017

VAERS ID: 158472 Before After
VAERS Form:
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 1 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 1 - / IM

Administered by: Other Unknown      Purchased by: Other Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 9/14/2017

VAERS ID: 158472 Before After
VAERS Form:(blank) 1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 1 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 1 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 2/14/2018

VAERS ID: 158472 Before After
VAERS Form:1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 6/14/2018

VAERS ID: 158472 Before After
VAERS Form:1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 8/14/2018

VAERS ID: 158472 Before After
VAERS Form:1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 9/14/2018

VAERS ID: 158472 Before After
VAERS Form:1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.


Changed on 10/14/2018

VAERS ID: 158472 Before After
VAERS Form:1
Age:11.0
Sex:Male
Location:Foreign
Vaccinated:2000-07-04
Onset:2000-07-05
Submitted:2000-08-01
Entered:2000-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 2 - / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER R10783 / 2 - / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 121011A / 2 - / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Malaise, Sepsis, Bacterial infection

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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:
Current Illness:
Preexisting Conditions: Obesity, metabolic disorder
Allergies:
Diagnostic Lab Data: Autopsy revealed cause of death as pneumococcal sepsis.
CDC 'Split Type': WAES00072420

Write-up: This 11-year-old male received vaxs and one day post vax, became "severely ill (not specified) and was admitted to the hospital. Reanimation was unsuccessful and the pt died. An autopsy was performed that revealed a pneumococcal sepsis," which was the cause of death. Severe malaise was also considered life threatening event.

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