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This is VAERS ID 164713

Case Details

VAERS ID: 164713 (history)  
Form: Version 1.0  
Age: 1.25  
Sex: Female  
Location: Massachusetts  
Vaccinated:2001-01-05
Onset:2001-01-06
   Days after vaccination:1
Submitted: 2001-01-08
   Days after onset:2
Entered: 2001-01-16
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0313AA / UNK RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 471876 / UNK RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1327J / UNK LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 473341 / UNK RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1869J / UNK LL / SC

Administered by: Private       Purchased by: Unknown
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2001-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Poliovax by Connaught, Lot #R0692 given SC
Current Illness: Constipation
Preexisting Conditions: Cerebral dysgenesis, congenital CMV, developmental delay
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/8/01, the physician received a phone call stating that the pt died on 1/6/01 in the A.M.


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