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This is VAERS ID 206895

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 206895
VAERS Form:
Age:1.0
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR, - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (UNKNOWN MFR) / UNKNOWN MFR - / - - / -
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATO - / - - / -
UNK: VACCINE NOT SPECIFIED / UNKNOWN MFR - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: APNEA, HEPATITIS, SEPSIS, ACIDOSIS, NECRO LIVER

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3"/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed


Changed on 12/30/2006

VAERS ID: 206895 Before After
VAERS Form:
Age:1.0
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR, - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (UNKNOWN MFR) / UNKNOWN MFR - / - - / -
PNC: PNEUMO, 7-VALENT (PREVNAR) / LEDERLE LABORATO - / - - / -
UNK: VACCINE NOT SPECIFIED / UNKNOWN MFR - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: APNEA, HEPATITIS, SEPSIS, ACIDOSIS, NECRO LIVER, NECRO LIVER

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3"/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed


Changed on 12/8/2009

VAERS ID: 206895 Before After
VAERS Form:
Age:1.0 1.3
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR, AVENTIS PASTEUR - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (UNKNOWN MFR) MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MFR UNKNOWN MANUFACTURER - / - - / -
PNC: PNEUMO, 7-VALENT (PREVNAR) PNEUMO (PREVNAR) / LEDERLE LABORATO LEDERLE LABORATORIES - / - - / -
UNK: VACCINE NOT SPECIFIED VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MFR UNKNOWN MANUFACTURER - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia, APNEA, HEPATITIS, SEPSIS, ACIDOSIS, NECRO LIVER

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': (blank) 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3"/17/03. 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 3/2/2010

VAERS ID: 206895 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / LEDERLE LABORATORIES - / - - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 4/7/2010

VAERS ID: 206895 Before After
VAERS Form:
Age:1.3
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / LEDERLE LABORATORIES - / - - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 2/14/2017

VAERS ID: 206895 Before After
VAERS Form:
Age:1.3 1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES - / - - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 5/14/2017

VAERS ID: 206895 Before After
VAERS Form:
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / AVENTIS PASTEUR SANOFI PASTEUR - / - - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PNC: PNEUMO (PREVNAR) / LEDERLE LABORATORIES PFIZER/WYETH - / - - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 9/14/2017

VAERS ID: 206895 Before After
VAERS Form:(blank) 1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / - UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / - UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 2/14/2018

VAERS ID: 206895 Before After
VAERS Form:1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 6/14/2018

VAERS ID: 206895 Before After
VAERS Form:1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 8/14/2018

VAERS ID: 206895 Before After
VAERS Form:1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 9/14/2018

VAERS ID: 206895 Before After
VAERS Form:1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.


Changed on 10/14/2018

VAERS ID: 206895 Before After
VAERS Form:1
Age:1.29
Sex:Female
Location:California
Vaccinated:2003-03-17
Onset:2003-05-22
Submitted:2003-07-23
Entered:2003-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR - / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH - / UNK - / -
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown      Purchased by: Unknown
Symptoms: Acidosis, Hepatic necrosis, Hepatitis, Renal failure, Respiratory failure, Sepsis, Thrombocytopenia

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2003-05-31
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': 200301423

Write-up: This subject is a one year old female, who was admitted to the hospital due to systemic inflammatory response syndrome while enrolled in a Phase IV Daptacel study. The subject received one dose of Daptacel vaccine: along with other pediatric vaccines on 3/17/03. The subject developed symptoms 65 days post immunization and was admitted to the hospital three days later 5/25/03. The subject was transferred from hospital to another hospital on 5/26/03 with the diagnosis of acute respiratory failure, presumed streptococcal sepsis and hepatitis. While at hospital, the pt expired on 5/31/03 with a diagnosis of SIRS, acidosis and acute liver necrosis. The event of systemic inflammatory response syndrome was reported by the investigator as unrelated to the study vaccine. No autopsy was performed. Follow up on 04/21/04: "New version created to place Infanrix into pt''s history screen." Medical Records received on 8/05/2003 states kidney failure and thrombocytopenia.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=206895&WAYBACKHISTORY=ON


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