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This is VAERS ID 35080

Case Details

VAERS ID: 35080 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Washington  
Vaccinated:1991-08-30
Onset:1991-08-30
   Days after vaccination:0
Submitted: 1991-09-06
   Days after onset:7
Entered: 1991-09-30
   Days after submission:24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 306924 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M140HD / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 306965 / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-08-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Instructed to use none; APAP if needed;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy
CDC Split Type: WA91618

Write-up: Pt died-SIDS on death certificate; Pt died evening p/immun were given; MD requested vax adverse rxn report be filed; Mom states pt did not seem to have had any reactions to the immun;


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