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This is VAERS ID 442402

History of Changes from the VAERS Wayback Machine

First Appeared on 11/14/2011

VAERS ID: 442402
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - RA / -
HPV: HPV (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - RA / -
MEN: MENINGOCOCCAL (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - RA / -

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderal,
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 12/14/2011

VAERS ID: 442402 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - RA / -
HPV: HPV (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - RA / -
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MEN: MENINGOCOCCAL (NO BRAND NAME) MENINGOCOCCAL (MENOMUNE) / UNKNOWN MANUFACTURER SANOFI PASTEUR - U4006AA / - RA / - IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderal,
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 1/15/2012

VAERS ID: 442402 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MEN: MENINGOCOCCAL (MENOMUNE) / SANOFI PASTEUR U4006AA / - RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderal,
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Record is removed as of 2/13/2013


Changed on 3/12/2013

VAERS ID: 442402 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderal, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 6/14/2014

VAERS ID: 442402 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 3/14/2015

VAERS ID: 442402 Before After
VAERS Form:
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 9/14/2017

VAERS ID: 442402 Before After
VAERS Form:(blank) 1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / - UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / - UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / - UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 2/14/2018

VAERS ID: 442402 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 6/14/2018

VAERS ID: 442402 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 8/14/2018

VAERS ID: 442402 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 9/14/2018

VAERS ID: 442402 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.


Changed on 10/14/2018

VAERS ID: 442402 Before After
VAERS Form:1
Age:15.0
Sex:Male
Location:Oregon
Vaccinated:2011-10-17
Onset:2011-10-17
Submitted:2011-11-14
Entered:2011-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. 1262AA / UNK RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4006AA / UNK RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS AC52B072EA / UNK RA / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Pain, Swelling

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Initial soreness and swelling. Death 10/20/2011.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=442402&WAYBACKHISTORY=ON


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