| VAERS ID: |
110675 (history) |
| Form: |
Version 1.0 |
| Age: |
0.17 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 1998-03-24 |
| Onset: | 1998-04-04 |
| Days after vaccination: | 11 |
| Submitted: |
1998-05-06 |
| Days after onset: | 31 |
| Entered: |
1998-05-07 |
| Days after submission: | 1 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH |
450639 / 1 |
RL / IM |
| HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM |
2404A2 / 2 |
RL / IM |
| HIBV: HIB (HIBTITER) / PFIZER/WYETH |
M285RJ / 1 |
LL / IM |
| IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. |
M1163 / 1 |
LA / SC |
Administered by: Unknown Purchased by: Unknown
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-04-04
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: pt recv pneumo study vax on 24MAR98 by Lederle, lot# B110
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: unk what tests were ordered;
CDC Split Type:
Write-up: pt recv vax 24MAR98 & pt died from SIDS 4APR98 presented @ hosp; | 