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This is VAERS ID 403759

Case Details

VAERS ID: 403759 (history)  
Form: Version 1.0  
Age: 10.0  
Gender: Male  
Location: New Jersey  
Vaccinated:2010-09-09
Onset:2010-09-17
   Days after vaccination:8
Submitted: 2010-10-15
   Days after onset:28
Entered: 2010-10-18
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (VAQTA) / MERCK & CO. INC. 0568Z / UNK RA / UN
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1778Y / UNK RA / UN
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR UA3058AA / UNK LA / UN
TDAP: TDAP (ADACEL) / SANOFI PASTEUR C3476AA / UNK LA / UN

Administered by: Unknown       Purchased by: Private
Symptoms: Asthenia, Death, Malaise
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2010-09-20
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Unknown
CDC Split Type:

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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