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This is VAERS ID 215919

Case Details

VAERS ID: 215919 (history)  
Form: Version 1.0  
Age: 1.0  
Sex: Female  
Location: Missouri  
Vaccinated:2003-12-09
Onset:2003-12-11
   Days after vaccination:2
Submitted: 2004-01-29
   Days after onset:49
Entered: 2004-02-04
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UA859AA / 4 LL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0100N / 1 LA / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 493264 / 4 RL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0544N / 1 LA / SC

Administered by: Public       Purchased by: Public
Symptoms: Diarrhoea
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2003-12-11
   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: NONE
Current Illness: NONE
Preexisting Conditions: Allergic to PCN
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: None. Had diarrhea 2 weeks before.


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