| VAERS ID: |
442402 (history) |
| Form: |
Version 1.0 |
| Age: |
15.0 |
| Sex: |
Male |
| Location: |
Oregon |
| Vaccinated: | 2011-10-17 |
| Onset: | 2011-10-17 |
| Days after vaccination: | 0 |
| Submitted: |
2011-11-14 |
| Days after onset: | 28 |
| Entered: |
2011-11-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| HPV4: HPV (GARDASIL) / MERCK & CO. INC. |
1262AA / UNK |
RA / IM |
| MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR |
U4006AA / UNK |
RA / IM |
| TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AC52B072EA / UNK |
RA / IM |
Administered by: Private Purchased by: Public
Symptoms: Death,
Pain,
Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2011-10-20
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote, Lyrica, Diazapam, Adderall
Current Illness: No
Preexisting Conditions: Seizure Disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Initial soreness and swelling. Death 10/20/2011. |
