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| VAERS ID: | 403759 (history) | Vaccinated: | 2010-09-09 | | Age: | 10.0 | Onset: | 2010-09-17, Days after vaccination: 8 | | Gender: | Male | Submitted: | 2010-10-15, Days after onset: 28 | | Location: | New Jersey | Entered: | 2010-10-18, Days after submission: 3 | |
| Life Threatening? Yes |
Died? Yes
Date died: 2010-09-20
Days after onset: 3 |
| Permanent Disability? No |
| Recovered? No | | ER or Doctor Visit? Yes |
| Hospitalized? No | | Previous Vaccinations: | | Other Medications: None | | Current Illness: None | | Preexisting Conditions: None | | Diagnostic Lab Data: Unknown | | CDC 'Split Type': | |
| Vaccination | Manufacturer | Lot | Dose | Route | Site | | HEPA: HEP A (VAQTA) | MERCK & CO. INC. | 0568Z | | UN | RA | | HPV4: HPV (GARDASIL) | MERCK & CO. INC. | 1778Y | | UN | RA | | MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) | SANOFI PASTEUR | UA3058AA | | UN | LA | | TDAP: TDAP (ADACEL) | SANOFI PASTEUR | C3476AA | | UN | LA | |
| Administered by: Unknown Purchased by: Private | Symptoms: Asthenia,
Death,
Malaise
SMQs:, Guillain-Barre syndrome (broad)
| | Write-up: Mother called me on 9-17-10 afternoon that her son is sick and feeling very weak. I recommended the mother to take him to nearest ER as the patient was about 50 miles away and mother took him to ER where he was transferred to another hospital. |
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