National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 64863

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 64863
VAERS Form:
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL / LEDERLE 355901 / 0 LL / IM
HEP: RECOMBIVAX HB / MSD 0417W / 0 RL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M010KD / 0 RL / IM
IPV: POLIOVAX / CONNAUGHT LTD J0690 / 0 LL / SC

Administered by: Private      Purchased by: Unknown
Symptoms: AGITATION, HYPOTONIA, STUPOR, APNEA, PALLOR

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 12/8/2009

VAERS ID: 64863 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-27 1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL DTP (TRI-IMMUNOL) / LEDERLE LEDERLE LABORATORIES 355901 / 0 LL / IM
HEP: RECOMBIVAX HB HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 0417W / 0 RL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M010KD / 0 RL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. J0690 / 0 LL / SC

Administered by: Private      Purchased by: Unknown Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor, AGITATION, HYPOTONIA, STUPOR, APNEA, PALLOR

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE (blank)

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 5/14/2017

VAERS ID: 64863 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 0 RL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M010KD / 0 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 0 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? 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: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 9/14/2017

VAERS ID: 64863 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 0 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 0 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 0 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 2/14/2018

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 6/14/2018

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 8/14/2018

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 9/14/2018

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 10/14/2018

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 12/24/2020

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 12/30/2020

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 5/7/2021

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing


Changed on 5/14/2021

VAERS ID: 64863 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Texas
Vaccinated:1994-06-27
Onset:1994-06-27
Submitted:1994-07-05
Entered:1994-07-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 355901 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0417W / 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010KD / 1 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. J0690 / 1 LL / SC

Administered by: Private      Purchased by: Public
Symptoms: Agitation, Apnoea, Hypotonia, Pallor, Stupor

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:1994-06-28
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recvd vax & went home midly fussy & 4 to 6 hrs later p/feeding & being laid supine was found limp/pale/apnic; irritable, cry, pale, unresponsive, not breathing

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=64863&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166