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This is VAERS ID 276107

Case Details

VAERS ID: 276107 (history)  
Form: Version 1.0  
Age:   
Gender: Unknown  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 2007-06-14
Entered: 2007-04-09
   Days after submission:66
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 654540/1162F / UNK UN / UN

Administered by: Other       Purchased by: Other
Symptoms: Medical device complication
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC Split Type: WAES0701USA01666

Write-up: Information has been received from a health professional who reported that a prefilled syringe (Lot # 654540/1162F) malfunctioned and the vaccine sprayed across the room. The patient did not miss being vaccinated with HPV rL1 6 11 16 18 VLP vaccine (yeast). Additional information has been requested. This is in follow-up to report (s) previously submitted on 4/6/2007. In follow-up it was reported by the nurse, that the patient did not receive any of the vaccine from the malfunctioning syringe. The patient received the GARDASIL from a completely new syringe. Follow-up information confirmed no known patient was identified or involved with the event. Therefore WAES #0701USA01666 is being deleted from our files. This report was previously sent in a quarterly submission to PLA V501 on 06-APR-2007. Additional information is not expected.


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