VAERS ID: |
113721 (history) |
Form: |
Version .0 |
Age: |
0.3 |
Sex: |
Male |
Location: |
New Jersey |
Vaccinated: | 1998-08-14 |
Onset: | 1998-08-23 |
Days after vaccination: | 9 |
Submitted: |
1998-08-26 |
Days after onset: | 3 |
Entered: |
1998-08-31 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES |
934790 / 1 |
RL / IM |
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES |
2699H2 / 1 |
LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. |
N0492 / 1 |
LL / IM |
Administered by: Private Purchased by: Private Symptoms: Unevaluable event SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 1998-08-23
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient Other Medications: NONE Current Illness: NONE Preexisting Conditions: NONE Allergies: Diagnostic Lab Data: gross autopsy reported to have shown no identifiable cause of death;pathology/tissue report pending; CDC Split Type:
Write-up: pt found lifeless in bed;head reported to have been wedged between mattress & wall; |