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This is VAERS ID 30808

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 30808
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP / CONNAUGHT LABS 1E21008 / 0 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) M1204A / 0 RL / IM
OPV: ORIMUNE / LEDERLE 297957 / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: AGITATION, DIARRHEA, POLYURIA

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': Intolerant to CM & Soy formulas x/soyalac

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 12/8/2009

VAERS ID: 30808 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-29 1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP DTP (NO BRAND NAME) / CONNAUGHT LABS CONNAUGHT LABORATORIES 1E21008 / 0 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M1204A / 0 RL / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 297957 / 0 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Agitation, Diarrhoea, Polyuria, AGITATION, DIARRHEA, POLYURIA

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': Intolerant to CM & Soy formulas x/soyalac (blank)

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 5/14/2017

VAERS ID: 30808 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 0 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M1204A / 0 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 297957 / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 9/14/2017

VAERS ID: 30808 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 0 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 0 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 0 1 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 2/14/2018

VAERS ID: 30808 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 6/14/2018

VAERS ID: 30808 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 8/14/2018

VAERS ID: 30808 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 9/14/2018

VAERS ID: 30808 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;


Changed on 10/14/2018

VAERS ID: 30808 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:1991-05-08
Onset:1991-05-10
Submitted:1991-05-17
Entered:1991-05-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 1E21008 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M1204A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 297957 / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Agitation, Diarrhoea, Polyuria

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-05-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: Intolerant to CM & Soy formulas x/soyalac
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt rec''d initial DPT/OPV/HIB developed fretful later the same day, rec''d APAP; Stools seemed loose; child voided more than usual; But looked OK next day, died unexpectedly in sleep;

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