| VAERS ID: |
436743 (history) |
| Form: |
Version .0 |
| Age: |
1.1 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2011-09-22 |
| Onset: | 2011-09-23 |
| Days after vaccination: | 1 |
| Submitted: |
2011-10-04 |
| Days after onset: | 11 |
| Entered: |
2011-10-04 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
UT4176BA / - |
RL / IM |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0404AA / 0 |
RL / SC |
| PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH |
916598 / 3 |
LL / IM |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0819AA / 0 |
LL / SC |
Administered by: Unknown Purchased by: Unknown
Symptoms: Cyanosis,
Death,
Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2011-09-23
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:
Current Illness: Cold/URI/ear infection
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Parents found patient blue and not breathing at home. Code Blue to hospital. | 