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This is VAERS ID 35477

Case Details

VAERS ID: 35477 (history)  
Form: Version 1.0  
Age: 5.0  
Sex: Male  
Location: Louisiana  
Vaccinated:1991-09-26
Onset:1991-09-26
   Days after vaccination:0
Submitted: 1991-09-30
   Days after onset:4
Entered: 1991-10-14
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES 1L21055 / 4 LA / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1904S / 2 RA / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 304966 / 5 MO / PO

Administered by: Public       Purchased by: Unknown
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1991-09-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: None known;~ ()~~~In patient
Other Medications:
Current Illness: None known;
Preexisting Conditions: Sz disorder, microcephaly, & mental retardation;
Allergies:
Diagnostic Lab Data: Unknown;
CDC Split Type: LA911001

Write-up: 27SEP91 recd call from friend of family informing Health Unit that PT died night of 26SEP91 @ hospital p/immunizations 26SEP91;


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