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This is VAERS ID 28873

Case Details

VAERS ID: 28873 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: New York  
Vaccinated:1991-01-28
Onset:1991-01-30
   Days after vaccination:2
Submitted: 1991-02-12
   Days after onset:13
Entered: 1991-03-07
   Days after submission:23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 289962 / UNK - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M740EN / UNK - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 283946 / UNK MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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:
Preexisting Conditions: birthweight 6 lbs, full term pregnancy; uncomplicated spontaneous delivery. Family hx of astham.
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: 910032401

Write-up: 2 mo infant rec''d DTP/OPV/HIB TITER on 28JAN91. Pt died (DATE & TIME UNKNOWN).


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