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This is VAERS ID 110009

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 110009
VAERS Form:
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 448451 / 0 RL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M255RJ / 0 LL / IM
IPV: POLIOVAX / CONNAUGHT LTD N0032 / 0 RA / SC

Administered by: Private      Purchased by: Unknown
Symptoms: SIDS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 12/8/2009

VAERS ID: 110009 Before After
VAERS Form:
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-24 1998-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 448451 / 0 RL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE LABORATORIES M255RJ / 0 LL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. N0032 / 0 RA / SC

Administered by: Private Unknown      Purchased by: Unknown
Symptoms: SIDS, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 5/14/2017

VAERS ID: 110009 Before After
VAERS Form:
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 448451 / 0 RL / IM
HIBV: HIB (HIBTITER) / LEDERLE LABORATORIES PFIZER/WYETH M255RJ / 0 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0032 / 0 RA / SC

Administered by: Unknown Private      Purchased by: Unknown Public
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 9/14/2017

VAERS ID: 110009 Before After
VAERS Form:(blank) 1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 448451 / 0 1 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M255RJ / 0 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N0032 / 0 1 RA / SC

Administered by: Private      Purchased by: Public
Symptoms: Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 2/14/2018

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 6/14/2018

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 8/14/2018

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 9/14/2018

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 10/14/2018

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 12/24/2020

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

Changed on 12/30/2020

VAERS ID: 110009 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Pennsylvania
Vaccinated:1998-03-26
Onset:1998-03-27
Submitted:1998-04-16
Entered:1998-04-23
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-27
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: 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;

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=110009&WAYBACKHISTORY=ON


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