National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 164713

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 164713
VAERS Form:
Age:1.3
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABS U0313AA / - RL / IM
HIBV: HIB (HIBTITER) / LEDERLE(PRAXIS) 471876 / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MSD 1327J / - LL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE 473341 / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MSD 1869J / - LL / SC

Administered by: Private      Purchased by: Unknown
Symptoms: REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 12/8/2009

VAERS ID: 164713 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABS CONNAUGHT LABORATORIES U0313AA / - RL / IM
HIBV: HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS 471876 / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MSD MERCK & CO. INC. 1327J / - LL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LEDERLE LABORATORIES 473341 / - RL / IM
VARCEL: VARICELLA (VARIVAX) VARICELLA (VARIVAX) / MSD MERCK & CO. INC. 1869J / - LL / SC

Administered by: Private      Purchased by: Unknown Other
Symptoms: Unevaluable event, REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 3/2/2010

VAERS ID: 164713 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0313AA / - RL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS 471876 / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1327J / - LL / SC
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES 473341 / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1869J / - LL / SC

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 4/7/2010

VAERS ID: 164713 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0313AA / - RL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS 471876 / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1327J / - LL / SC
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES 473341 / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1869J / - LL / SC

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 2/14/2017

VAERS ID: 164713 Before After
VAERS Form:
Age:1.3 1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0313AA / - RL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS 471876 / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1327J / - LL / SC
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES 473341 / - RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1869J / - LL / SC

Administered by: Private      Purchased by: Other
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 5/14/2017

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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 9/14/2017

VAERS ID: 164713 Before After
VAERS Form:(blank) 1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 2/14/2018

VAERS ID: 164713 Before After
VAERS Form:1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 6/14/2018

VAERS ID: 164713 Before After
VAERS Form:1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 8/14/2018

VAERS ID: 164713 Before After
VAERS Form:1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 9/14/2018

VAERS ID: 164713 Before After
VAERS Form:1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.


Changed on 10/14/2018

VAERS ID: 164713 Before After
VAERS Form:1
Age:1.25
Sex:Female
Location:Massachusetts
Vaccinated:2001-01-05
Onset:2001-01-06
Submitted:2001-01-08
Entered:2001-01-16
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-01-06
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: 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.

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=164713&WAYBACKHISTORY=ON


Copyright © 2019 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166