| VAERS ID: |
485757 (history) |
| Form: |
Version 1.0 |
| Age: |
11.0 |
| Sex: |
Female |
| Location: |
New York |
| Vaccinated: | 2013-02-19 |
| Onset: | 2013-02-19 |
| Days after vaccination: | 0 |
| Submitted: |
2013-02-25 |
| Days after onset: | 6 |
| Entered: |
2013-02-28 |
| Days after submission: | 3 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AHAVB677CA / UNK |
UN / UN |
| HPV4: HPV (GARDASIL) / MERCK & CO. INC. |
H016238 / UNK |
UN / UN |
| MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR |
U42927 / UNK |
UN / UN |
| TDAP: TDAP (ADACEL) / SANOFI PASTEUR |
U4431BA / UNK |
UN / UN |
Administered by: Private Purchased by: Unknown
Symptoms: Cardiac arrest,
Crying,
Death,
Endotracheal intubation,
Respiratory arrest,
Skin discolouration
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2013-02-20
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: DILANTIN; Phenobarb
Current Illness: Medical record - cough - resp sym x 5 days (doc denies)
Preexisting Conditions: Microcephaly; seizure
Allergies:
Diagnostic Lab Data: See reverse
CDC Split Type:
Write-up: 2/19/13 23:24 Pt brought in by ambulance in cardiac arrest, "mother states pt has been having cough & URI symptoms since 5 days - seen by doctor 2/19/13 & given 4 vaccines. Pt sleeping & crying - suddenly pt turned white & was not breathing - 911 called & intubated. Doctor states he was not aware of any illness & child''s DILANTIN level was 1.0. No lab found in medical record child revived & transfer to another hospital where child died on 2/20/13. |
