VAERS ID: |
110009 (history) |
Form: |
Version 1.0 |
Age: |
0.1 |
Sex: |
Female |
Location: |
Pennsylvania |
Vaccinated: | 1998-03-26 |
Onset: | 1998-03-27 |
Days after vaccination: | 1 |
Submitted: |
1998-04-16 |
Days after onset: | 19 |
Entered: |
1998-04-23 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH |
448451 / 1 |
RL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH |
M255RJ / 1 |
LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. |
N0032 / 1 |
RA / SC |
Administered by: Private Purchased by: Public Symptoms: Sudden infant death syndrome SMQs:, Neonatal disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-03-27
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: NONE Current Illness: NONE Preexisting Conditions: +suspected sepsis @ birth treated x 7 days Allergies: Diagnostic Lab Data: NA CDC Split Type:
Write-up: pt recv vax 26MAR98 & died 27MAR98; |