VAERS ID: |
162631 (history) |
Form: |
Version 1.0 |
Age: |
0.2 |
Sex: |
Male |
Location: |
Michigan |
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-15 |
Days after vaccination: | 1 |
Submitted: |
2000-11-20 |
Days after onset: | 5 |
Entered: |
2000-11-28 |
Days after submission: | 8 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM |
96042 / 1 |
LL / IM |
HIBV: HIB (HIBTITER) / PFIZER/WYETH |
473007 / 1 |
LL / IM |
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. |
R0691 / 1 |
RL / IM |
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
473337 / 1 |
RL / IM |
Administered by: Private Purchased by: Other Symptoms: Sudden infant death syndrome SMQs:, Neonatal disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-11-15
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: NONE Allergies:
Diagnostic Lab Data: autopsy - nml CDC Split Type:
Write-up: The pt died from SIDS within 24 hours post vax. |