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This is VAERS ID 501663

History of Changes from the VAERS Wayback Machine

First Appeared on 9/17/2013

VAERS ID: 501663
VAERS Form:
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 0 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 1 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 9/14/2017

VAERS ID: 501663 Before After
VAERS Form:(blank) 1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 0 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 1 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 2/14/2018

VAERS ID: 501663 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 6/14/2018

VAERS ID: 501663 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 8/14/2018

VAERS ID: 501663 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 9/14/2018

VAERS ID: 501663 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.


Changed on 10/14/2018

VAERS ID: 501663 Before After
VAERS Form:1
Age:17.0
Sex:Female
Location:Michigan
Vaccinated:2013-08-09
Onset:2013-08-22
Submitted:2013-08-30
Entered:2013-09-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. H020848 / 1 UN / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U4584BA / 2 UN / IM

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-08-22
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:
Current Illness:
Preexisting Conditions: No known allergies.
Allergies:
Diagnostic Lab Data: Not reported
CDC 'Split Type': 201309264

Write-up: Initial report was received 26 August 2013 from a health care professional. A 17-year-old female patient with no known allergies had received a second dose intramuscular injection of MENACTRA, lot number U4584BA and a first dose intramuscular injection of GARDASIL (manufacturer Merck, lot number H020848) (sites of administration not reported) on 09 August 2013, and 13 days later on 22 August 2013, the patient died. There was no contact with the physician after MENACTRA had been given. The patient had previously received a first dose injection of MENACTRA on 04 September 2008. The reporter had been contacted by the county medical examiner who informed the reporter about the death and requested the patient''s medical history. The reporter contacted the CDC (Centers for Disease Control and Prevention) who told them to call and report the event to VAERS. No additional information was provided at the time of the report. Documents held by sender: None.

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