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This is VAERS ID 436743

Case Details

VAERS ID: 436743 (history)  
Age: 1.06  
Gender: Male  
Location: Minnesota  
Vaccinated:2011-09-22
Onset:2011-09-23
   Days after vaccination:1
Submitted: 2011-10-04
   Days after onset:11
Entered: 2011-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4176BA / - RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0404AA / 0 RL / SC
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916598 / 3 LL / IM
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0819AA / 0 LL / SC

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cyanosis, Death, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Died? Yes
   Date died: 2011-09-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: Cold/URI/ear infection
Preexisting Conditions: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Parents found patient blue and not breathing at home. Code Blue to hospital.


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