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This is VAERS ID 276107

Case Details

VAERS ID: 276107 (history)  
Form: Version 1.0  
Gender: Unknown  
Location: New York  
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

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
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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