VAERS ID: |
473483 (history) |
Form: |
Version 1.0 |
Age: |
31.0 |
Sex: |
Male |
Location: |
Oklahoma |
Vaccinated: | 2012-10-30 |
Onset: | 2012-10-31 |
Days after vaccination: | 1 |
Submitted: |
2012-11-07 |
Days after onset: | 7 |
Entered: |
2012-11-07 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AHAVB566AN / UNK |
LA / IM |
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR |
H1354 / UNK |
LA / IM |
TYP: TYPHOID LIVE ORAL TY21A (VIVOTIF) / BERNA BIOTECH, LTD. |
3000128 / UNK |
MO / PO |
YF: YELLOW FEVER (YF-VAX) / SANOFI PASTEUR |
UH296AB / UNK |
LA / SC |
Administered by: Private Purchased by: Private Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2012-10-31
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: Soma Current Illness: No Preexisting Conditions: None Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: Pronounced dead at home in bed. |