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This is VAERS ID 403759
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? Yes, ? days
Extended hospital stay? No Previous Vaccinations: Other Medications: 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,
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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