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This is VAERS ID 604092

History of Changes from the VAERS Wayback Machine

First Appeared on 11/14/2015

VAERS ID: 604092
VAERS Form:
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / - UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 12/14/2016

VAERS ID: 604092 Before After
VAERS Form:
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UN / UN
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / - UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 9/14/2017

VAERS ID: 604092 Before After
VAERS Form:(blank) 1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / - UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / - UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 2/14/2018

VAERS ID: 604092 Before After
VAERS Form:1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 6/14/2018

VAERS ID: 604092 Before After
VAERS Form:1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 8/14/2018

VAERS ID: 604092 Before After
VAERS Form:1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 9/14/2018

VAERS ID: 604092 Before After
VAERS Form:1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.


Changed on 10/14/2018

VAERS ID: 604092 Before After
VAERS Form:1
Age:2.0
Sex:Male
Location:Georgia
Vaccinated:2015-10-19
Onset:2015-10-19
Submitted:2015-10-22
Entered:2015-10-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK UN / SC
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. - / UNK UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Cardiac arrest, Death, Resuscitation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2015-10-19
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No other medications
Current Illness: Prophylaxis
Preexisting Conditions: Cardiac operation; Heart disease congenital
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': WAES1510USA009311

Write-up: This spontaneous report as received from a physician via a company representative refers to an approximately 2.5 year old male patient. The patient''s medical history included "hyperplastic left heart" and multiple unspecified heart surgeries. There was no information about the patient''s concurrent conditions or concomitant therapies provided. On 19-OCT-2015, at 12:30, the patient was vaccinated with a dose of M-M-R II, subcutaneously (lot # and expiration date were not reported), a dose of VARIVAX (Merck) (route of administration, lot # and expiration date were not reported) and a dose of an unspecified flu vaccine. On 19-OCT-2015, at 12:50, the patient was brought back to the provider''s office, apparently in cardiac arrest. The reporter stated they began performing cardiopulmonary resuscitation (CPR) on the patient and called for an ambulance. The ambulance took the patient to an emergency room. The reporter stated they received a call from the coroner''s office at 15:00, and was informed that the child died (on 19-OCT-2015). The event of cardiac arrest was reported as life threatening. The outcome of cardiac arrest was reported as fatal, however the cause of death was not provided. The relatedness between the adverse event and suspect therapies was not reported. Upon internal review, the event of cardiac arrest was considered to be medically significant. Additional information has been requested.

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