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This is VAERS ID 179127

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History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 179127
VAERS Form:
Age:0.3
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE DTPA514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MSD 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABS UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) /   T13902 / 0 LL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE 480900 / 0 RL / IM

Administered by: Public      Purchased by: Unknown
Symptoms: STUPOR, DEATH

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in bot"h eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept


Changed on 12/30/2006

VAERS ID: 179127 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE DTPA514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MSD 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABS UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) /   T13902 / 0 LL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE 480900 / 0 RL / IM

Administered by: Public      Purchased by: Unknown
Symptoms: STUPOR, DEATH

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d dx''''d URI with nasal congestion. He had green matter in bot"h bo"th eyes and that was dx''d dx''''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept Dep


Changed on 12/8/2009

VAERS ID: 179127 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE GLAXOSMITHKLINE BIOLOGICALS DTPA514A2 514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABS CONNAUGHT LABORATORIES UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) /   AVENTIS PASTEUR T13902 / 0 LL / SC
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LEDERLE LABORATORIES 480900 / 0 RL / IM

Administered by: Public      Purchased by: Unknown Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema, STUPOR, DEATH

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago. ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''''d dx''d URI with nasal congestion. He had green matter in bo"th both eyes and that was dx''''d dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dep Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 3/2/2010

VAERS ID: 179127 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / AVENTIS PASTEUR T13902 / 0 LL / SC
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES 480900 / 0 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 4/7/2010

VAERS ID: 179127 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / AVENTIS PASTEUR T13902 / 0 LL / SC
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES 480900 / 0 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 2/14/2017

VAERS ID: 179127 Before After
VAERS Form:
Age:0.3 0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / AVENTIS PASTEUR T13902 / 0 LL / SC
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES 480900 / 0 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 5/14/2017

VAERS ID: 179127 Before After
VAERS Form:
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 1 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / AVENTIS PASTEUR SANOFI PASTEUR T13902 / 0 LL / SC
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES PFIZER/WYETH 480900 / 0 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 9/14/2017

VAERS ID: 179127 Before After
VAERS Form:(blank) 1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 0 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 1 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 0 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 0 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 2/14/2018

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 6/14/2018

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 8/14/2018

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 9/14/2018

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 10/14/2018

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 12/24/2020

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 12/30/2020

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 5/7/2021

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.


Changed on 5/21/2021

VAERS ID: 179127 Before After
VAERS Form:1
Age:0.25
Sex:Male
Location:Missouri
Vaccinated:2001-11-27
Onset:2001-12-12
Submitted:2001-12-13
Entered:2001-12-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS 514A2 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1067L / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES UA604AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / SANOFI PASTEUR T13902 / 1 LL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 480900 / 1 RL / IM

Administered by: Public      Purchased by: Public
Symptoms: Atelectasis, Coma, Eye discharge, Liver disorder, Nasal congestion, Nephritis, Petechiae, Pulmonary congestion, Pulmonary oedema

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2001-12-12
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: Completed antibiotic therapy 1 week ago for upper respiratory infection.
Current Illness: NONE
Preexisting Conditions: Respiratory infection 2-3 weeks ago.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC 'Split Type':

Write-up: The parent reports the pt did not have any problems after his shots. He had an upper respiratory infection about 2-3 weeks ago and completed antibiotics about 1 week ago. He was seen in ER. The ER dx''d URI with nasal congestion. He had green matter in both eyes and that was dx''d as conjunctivitis and treated with Polysporin optical ointment. The child was fed a bottle of Enfamil with Iron about 10:00 and was found unresponsive and pronounced DOA at 11:41 at the hospital. The hospital will fax Health Dept report. The baby was found by coroner with a bottle propped in the crib with a pillow and stuffed animals. COD as per autopsy report -- undetermined. Per F/U 4/13/02: Pleural surfaces have focal petechiae and are atelectatic. Lungs show edema and congestion, the liver shows congestion and the kidneys show a focal area of chronic inflammation.

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