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This is VAERS ID 58817

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 58817
VAERS Form:
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPH: TETRAMUNE / LEDERLE 358985 / - A / IM
HEP: RECOMBIVAX HB / MSD 1043W / - L / IM
MMR: MMR II / MSD 0961W / - L / IM
OPV: ORIMUNE / LEDERLE 0686B / - - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 12/8/2009

VAERS ID: 58817 Before After
VAERS Form:
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-10 1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPH: TETRAMUNE / LEDERLE 358985 / - A / IM
DTPHIB: DTP + HIB (TETRAMUNE) / LEDERLE LABORATORIES 358985 / - A / IM
HEP: RECOMBIVAX HB HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 1043W / - L / IM
MMR: MMR II MEASLES + MUMPS + RUBELLA (MMR II) / MSD MERCK & CO. INC. 0961W / - L / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 0686B / - - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Unevaluable event, REACT UNEVAL

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE (blank)

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 5/14/2017

VAERS ID: 58817 Before After
VAERS Form:
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 358985 / - A - / IM IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / - L - / IM IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / - L - / IM IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 0686B / - - / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 9/14/2017

VAERS ID: 58817 Before After
VAERS Form:(blank) 1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / - UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / - UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / - UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / - UNK - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 2/14/2018

VAERS ID: 58817 Before After
VAERS Form:1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 6/14/2018

VAERS ID: 58817 Before After
VAERS Form:1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 8/14/2018

VAERS ID: 58817 Before After
VAERS Form:1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 9/14/2018

VAERS ID: 58817 Before After
VAERS Form:1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;


Changed on 10/14/2018

VAERS ID: 58817 Before After
VAERS Form:1
Age:1.9
Sex:Female
Location:Montana
Vaccinated:1993-10-15
Onset:1993-10-25
Submitted:1993-12-27
Entered:1994-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 358985 / UNK - / IM A
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1043W / UNK - / IM L
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0961W / UNK - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0686B / UNK MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1993-10-25
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: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: sudden death; atuopsy report-cause of death remains undetermined; The poss of a sudden arrhythmia based on a morphologic abnormality of the conducting system of the heart will be investigated further;

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=58817&WAYBACKHISTORY=ON


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