VAERS ID: |
110675 (history) |
Form: |
Version .0 |
Age: |
0.2 |
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: |
1998-05-11 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAP: ACEL-IMUNE / LEDERLE |
450639 / 0 |
RL / IM |
HEP: ENGERIX-B / SMITHKLINE |
2404A2 / 1 |
RL / IM |
HIBV: HIBTITER / LEDERLE(PRAXIS) |
M285RJ / 0 |
LL / IM |
IPV: POLIOVAX / CONNAUGHT LTD |
M1163 / 0 |
LA / SC |
Administered by: Private Purchased by: Unknown Symptoms: SIDS 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: unk 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: NONE
Write-up: pt recv vax 24MAR98 & pt died from SIDS 4APR98 presented @ hosp; |