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VAERS ID: 77619 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: New York  
Vaccinated:1995-08-28
Onset:1995-08-28
   Days after vaccination:0
Submitted: 1995-08-28
   Days after onset:0
Entered: 1995-09-25
   Days after submission:28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 394957 / 2 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 390926 / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Cardiac arrest, Pyrexia, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: prematurity @ 28 wks
Allergies:
Diagnostic Lab Data:
CDC Split Type: NYS95047

Write-up: pt exp cardiac arrest about 2 1/2 hrs p/vax; was sleeping @ time t99.0; ? SIDS


VAERS ID: 77666 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Female  
Location: North Carolina  
Vaccinated:1995-08-07
Onset:1995-08-30
   Days after vaccination:23
Submitted: 1995-09-05
   Days after onset:6
Entered: 1995-09-26
   Days after submission:21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4M51065 / 3 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1162A / 3 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010LD / 3 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0716M / 3 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Haemorrhage, Pericarditis, Petechiae, Pulmonary oedema, Right ventricular failure, Stupor, Sudden infant death syndrome, Vasodilatation
SMQs:, Cardiac failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Pulmonary hypertension (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Neonatal disorders (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-08-30
   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: NONE
Current Illness: NONE
Preexisting Conditions: functional heart murmur; hx poor wt gain-resolving
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: NC95093

Write-up: was found unresponsive & bleeding out of mouth by mom while both were in bed time approx 3Am as reported by mom;


VAERS ID: 77681 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Tennessee  
Vaccinated:1995-02-23
Onset:1995-03-18
   Days after vaccination:23
Submitted: 1995-09-13
   Days after onset:178
Entered: 1995-09-27
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 384977 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1061A / 1 LL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0714A / 1 MO / PO

Administered by: Public       Purchased by: Unknown
Symptoms: Agitation, Apnoea, Cardiac arrest, Convulsion, Delirium, Hypertonia, Mydriasis, Somnolence, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (narrow), Parkinson-like events (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-03-18
   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: NONE
Preexisting Conditions: lt testicular hydrocele
Allergies:
Diagnostic Lab Data:
CDC Split Type: TN95099

Write-up: frothy sputum 3 days onset to death date crankiness & excessive somnolence to date of death; suspect benign sz found in decerebrate position, diaphoretic, fists clenched, CPR started, no results pupils remained blown-& non reactive


VAERS ID: 77775 (history)  
Form: Version 1.0  
Age: 0.6  
Sex: Female  
Location: Illinois  
Vaccinated:1995-08-14
Onset:1995-08-14
   Days after vaccination:0
Submitted: 1995-08-22
   Days after onset:8
Entered: 1995-09-29
   Days after submission:38
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 384975 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0719A / 1 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Bronchiolitis, Cardiac arrest, Cardiovascular disorder, Pneumonia, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-08-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: APAP; Theophylline/PVS/?
Current Illness: GA-26wks, RDS, ASD, ROP gr III
Preexisting Conditions: GA-26wks, RDS, ASD, ROP gr III, pulmonary hemorrhage, parainfluenza, pneumonia, periventricularapt
Allergies:
Diagnostic Lab Data: autopsy results/per death cert - Cardiorespiratory failure & acute bronchopneumonia w/bronchiolitis
CDC Split Type: IL950104

Write-up: pt devel T102 few hrs p/vax given;was seen by PMD 1 wk before for OM;MD called re: fever & given APAP as ordered;pt in route to ER when pt arrested & taken to ER;hosp unable to revive pt


VAERS ID: 77777 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Pennsylvania  
Vaccinated:1995-09-11
Onset:1995-09-13
   Days after vaccination:2
Submitted: 1995-09-15
   Days after onset:2
Entered: 1995-09-29
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4J51138 / 1 RL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1658A2 / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4J51138 / 1 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0720F / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Ascites, Atelectasis, Cardiac arrest, Cardiomegaly, Cardiovascular disorder, Heart disease congenital, Salivary hypersecretion
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Congenital, familial and genetic disorders (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-13
   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: NONE
Preexisting Conditions: congenital dislocated rt hip
Allergies:
Diagnostic Lab Data: autopsy 14SEP95-congenital heart disease;
CDC Split Type: PA95193

Write-up: child in foster care; pt lying on the floor eve of 13SEP95 started to gurgle; foster mom picked up & pt ceased to breath; no fever, excessive crying, etc from immunizations


VAERS ID: 77779 (history)  
Form: Version 1.0  
Age: 62.0  
Sex: Female  
Location: Ohio  
Vaccinated:1992-12-17
Onset:1992-12-21
   Days after vaccination:4
Submitted: 1995-04-03
   Days after onset:832
Entered: 1995-09-29
   Days after submission:179
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
OPV: POLIO VIRUS, ORAL (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
TD: TD ADSORBED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
TYP: TYPHOID VI POLYSACCHARIDE (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
YF: YELLOW FEVER (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Arteriosclerosis, Cardiovascular disorder, Coronary artery disease, Hepatic steatosis, Pulmonary oedema
SMQs:, Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1992-12-21
   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:
Preexisting Conditions: precordial pressure, amenstic, arthralgia, clonoscopy, discomfort, abd diverticulosis, chest pain, hemturia, fatigue, hx chest pain, hematuria, obesity, loss memory, dyspnea, exertional
Allergies:
Diagnostic Lab Data: EKG 10/30/84/WNL; 9/21/87/WNL; 8/3/88/WNL; EKG 9/26/88/WNL; 10/24/91; CXR WNL; 10AUG82 serum cholesterol 223; triglyceride 112; 28JUN94 serum cholesterol 213; triglyceride 87; 15JAN86 serum cholesterol 192; triglyceride 107;
CDC Split Type:

Write-up: pt recvd vax & was found dead @ home 11:23 as on 21DEC92; 23DEC92 autopsy determined COD to be arteriosclerosis, gen, severe, w/moderately stenosing calcific coronary atherosclerosis;


VAERS ID: 77839 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1995-09-26
Onset:1995-09-27
   Days after vaccination:1
Submitted: 1995-09-28
   Days after onset:1
Entered: 1995-10-02
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 394956 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1658A2 / UNK RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0717D / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Agitation, Hypotonia
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: pt recvd vax & became limp @ 9AM when care taker was dressing pt; called 911 taken to ER-mom was called about 10AM on 27SEP95 reported that pt had died; pt was a little fussy-autopsy done did not find any trauma according to mom;


VAERS ID: 77840 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Tennessee  
Vaccinated:1995-08-25
Onset:1995-08-29
   Days after vaccination:4
Submitted: 1995-09-19
   Days after onset:21
Entered: 1995-10-02
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 384976 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 398928 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-08-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: pt recvd HEP by Engerix lot# 1537B9 & 1607B9 on 7JUN95 & 12JUL95
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt found deceased (@ home) 29AUG95; ER MD states is SIDS death; family has not obtained final autopsy report


VAERS ID: 78020 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Illinois  
Vaccinated:1995-09-28
Onset:1995-09-29
   Days after vaccination:1
Submitted: 1995-10-03
   Days after onset:4
Entered: 1995-10-11
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 5H61047 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 382946 / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Lung disorder, Pulmonary oedema, Sudden infant death syndrome
SMQs:, Cardiac failure (narrow), Acute central respiratory depression (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: none~ ()~~~In patient
Other Medications: hep vax on 17aug95
Current Illness: well child
Preexisting Conditions: pneumonia 7sep95;
Allergies:
Diagnostic Lab Data: autopsy performed
CDC Split Type:

Write-up: pt recvd vax;baby found sleepy face down in crib by mom; not breathing; to er by amb;SIDS at 8:56pm;


VAERS ID: 78092 (history)  
Form: Version 1.0  
Age: 56.0  
Sex: Male  
Location: New York  
Vaccinated:1995-09-27
Onset:1995-09-28
   Days after vaccination:1
Submitted: 1995-10-04
   Days after onset:6
Entered: 1995-10-13
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4958109 / UNK - / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Cardiac arrest, Coronary artery disease
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Micronase
Current Illness:
Preexisting Conditions: no noted symptomatic heart disease-did have poorly controlled DM
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt had coronary event 12 hrs p/vax autopsy showed only CAD-pt had sudden death clinically


VAERS ID: 78297 (history)  
Form: Version 1.0  
Age: 90.0  
Sex: Male  
Location: Minnesota  
Vaccinated:1995-10-02
Onset:1995-10-13
   Days after vaccination:11
Submitted: 1995-10-16
   Days after onset:3
Entered: 1995-10-24
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4958074 / UNK RA / -
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 390928 / UNK LA / -

Administered by: Private       Purchased by: Private
Symptoms: Guillain-Barre syndrome, Hypokalaemia
SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Hypokalaemia (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: guillain-Barre synd-hypokalemia


VAERS ID: 78301 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Female  
Location: Pennsylvania  
Vaccinated:1995-10-17
Onset:1995-10-18
   Days after vaccination:1
Submitted: 1995-10-18
   Days after onset:0
Entered: 1995-10-24
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428037 / 2 - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0724A / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Rash
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: facial rash 18OCTAM-death 18OCT afternoon;


VAERS ID: 78385 (history)  
Form: Version 1.0  
Age: 82.0  
Sex: Male  
Location: New Jersey  
Vaccinated:1993-09-27
Onset:1994-06-05
   Days after vaccination:251
Submitted: 1995-10-17
   Days after onset:499
Entered: 1995-10-25
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
PPV: PNEUMO (PNEUMOVAX) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Lung neoplasm malignant
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1994-06-05
   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: CHF, COPD
Preexisting Conditions: CHF, COPD
Allergies:
Diagnostic Lab Data: No relevant data;
CDC Split Type: WAES95100020

Write-up: pt recvd vax 27SEP93 & devel lung cancer; 7DEC93 MD noted that the pt was well;5JUN94 pt died; COD unk; addtl details have been requested;


VAERS ID: 78453 (history)  
Form: Version 1.0  
Age:   
Sex: Male  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 1995-10-10
Entered: 1995-10-30
   Days after submission:20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Condition aggravated, Embolism, Hyperventilation, Hypotension, Infection, Pneumonia, Pyrexia, Vomiting
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: COPD
Preexisting Conditions: COPD
Allergies:
Diagnostic Lab Data:
CDC Split Type: 895289005S

Write-up: pt recvd vax & devel poss complications of the pre-existing COPD & was hospital;addtl info recvd 13OCT95 revealed that pt died while in hosp


VAERS ID: 78518 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Female  
Location: Minnesota  
Vaccinated:0000-00-00
Onset:1995-10-19
Submitted: 1995-10-27
   Days after onset:8
Entered: 1995-10-31
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4958112 / UNK LA / IM

Administered by: Other       Purchased by: Public
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: IHSS, Bipolar disorder, Dementia
Preexisting Conditions: IHSS, Bipolar disorder, Dementia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death (pt was found dead in the bathroom by husband, prev to this no complaints) no tx; no evaluation post mortem, data gather from conversation w/husband


VAERS ID: 78583 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Florida  
Vaccinated:1995-08-16
Onset:0000-00-00
Submitted: 1995-10-16
Entered: 1995-11-02
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 390955 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1407A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0719K / 1 MO / PO

Administered by: Public       Purchased by: Unknown
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-01
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: probable lt inginual hernia
Preexisting Conditions: discordant twin w/2 knots in umbilical cord-intrauterine, retardation
Allergies:
Diagnostic Lab Data:
CDC Split Type: FL95066

Write-up: pending dx of COD SIDS


VAERS ID: 78584 (history)  
Form: Version 1.0  
Age: 0.6  
Sex: Female  
Location: Florida  
Vaccinated:1995-05-10
Onset:0000-00-00
Submitted: 1995-10-16
Entered: 1995-11-02
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4A61098 / 3 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1291A / 3 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M005LK / 3 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0714D / 3 MO / PO

Administered by: Public       Purchased by: Unknown
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-07-30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: FL95070

Write-up: Pending dx COD: SIDS


VAERS ID: 78670 (history)  
Form: Version 1.0  
Age: 1.3  
Sex: Female  
Location: New York  
Vaccinated:1995-05-24
Onset:1995-06-06
   Days after vaccination:13
Submitted: 1995-10-31
   Days after onset:147
Entered: 1995-11-06
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0640A / UNK - / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0552A / UNK - / -

Administered by: Private       Purchased by: Unknown
Symptoms: Apnoea, Cardiac arrest, Convulsion, Delirium, Encephalopathy, Pallor, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Chronic kidney disease (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-06-10
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: p/receiving vax feverish & very pale-took pt for blood work 4 days prior to death-due to paleish face;went into a sx disorder & went into cardiac arrest was pronounced dead on arrival;


VAERS ID: 78716 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Wisconsin  
Vaccinated:1995-10-27
Onset:1995-10-29
   Days after vaccination:2
Submitted: 1995-10-31
   Days after onset:2
Entered: 1995-11-07
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428035 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0767B / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0726A / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Agitation, Pyrexia, Sudden infant death syndrome, Unevaluable event
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: 31b 14oz 377wk gestation
Allergies:
Diagnostic Lab Data: autopsy being done-@ this time definite causation for death found, likely falls into category of SIDS
CDC Split Type:

Write-up: mild fever some irritability; death;reporter states this is a poss adverse event w/a time assoc to vax;cannot determine cause (vaccine?/effect (death);pt low nl birth weight; sleep position abdomen


VAERS ID: 78870 (history)  
Form: Version 1.0  
Age: 70.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1995-09-24
Onset:1995-09-24
   Days after vaccination:0
Submitted: 1995-11-04
   Days after onset:41
Entered: 1995-11-13
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E2835HA / 1 - / IM

Administered by: Other       Purchased by: Private
Symptoms: Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt admitted w/sepsis synd 24 hrs pos vax cultures neg;pt expired;no autopsy;acute sepsis synd poss d/t vax


VAERS ID: 78939 (history)  
Form: Version 1.0  
Age: 11.0  
Sex: Female  
Location: Kansas  
Vaccinated:1995-05-12
Onset:1995-05-19
   Days after vaccination:7
Submitted: 1995-11-07
   Days after onset:172
Entered: 1995-11-14
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1052A / 2 LL / -

Administered by: Public       Purchased by: Other
Symptoms: Agitation, Anorexia, Convulsion, Leukocytosis, Pneumonia
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1995-05-22
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: pt severely disabled @ 6wks w/DTP dose 1~ ()~~~In patient
Other Medications: Depakote, Lamictal
Current Illness: NONE
Preexisting Conditions: severely mentally & physically disabled-uncontrolled sz disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pneumonia w/inc szs, 19MAY95 restless, poor appetite, 22MAY95 afeb elevated WBC, prolonged szs just prior to code (epileptic status) lasted $g30mins


VAERS ID: 78972 (history)  
Form: Version 1.0  
Age: 5.0  
Sex: Male  
Location: Georgia  
Vaccinated:1995-10-11
Onset:1995-10-18
   Days after vaccination:7
Submitted: 1995-10-24
   Days after onset:6
Entered: 1995-11-16
   Days after submission:23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0213A / 1 LA / IM

Administered by: Public       Purchased by: Public
Symptoms: Adrenal insufficiency, Apnoea, Cardiac arrest, Coagulopathy, Haemorrhage, Meningitis, Myocarditis, Petechiae, Sepsis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious meningitis (narrow), Cardiomyopathy (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: blood culture positive Neisseria meningitis
CDC Split Type: GA95179

Write-up: 13OCT95 pt returned for PPD check & was having no problems;18OCT95 woke up vomiting, had elevated temp & weakness;In full arrest on arrival @ ER;deceased;blood culture & preliminary autopsyconfirm meningococcal meningitis


VAERS ID: 79259 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Florida  
Vaccinated:1995-08-21
Onset:0000-00-00
Submitted: 1995-11-01
Entered: 1995-11-20
   Days after submission:19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 390955 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1407A / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0719K / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: COD pending
CDC Split Type: FL95077

Write-up:


VAERS ID: 79260 (history)  
Form: Version 1.0  
Age: 75.0  
Sex: Male  
Location: Florida  
Vaccinated:1995-10-16
Onset:1995-10-17
   Days after vaccination:1
Submitted: 1995-10-18
   Days after onset:1
Entered: 1995-11-20
   Days after submission:33
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 5F61148 / 1 LA / -
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 390968 / 1 RA / -

Administered by: Public       Purchased by: Public
Symptoms: Cardiovascular disorder, Convulsion, Insomnia, Pain
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: died @ heart of Florida hosp
CDC Split Type: FL95079

Write-up: heart attack, ate dinner, rode bike on 16OCT95 p/vax; aching & diff sleeping noc of 16OCT95;sz on 17OCT95 to ER per ambulance


VAERS ID: 79262 (history)  
Form: Version 1.0  
Age: 0.8  
Sex: Male  
Location: Texas  
Vaccinated:1995-10-16
Onset:1995-10-17
   Days after vaccination:1
Submitted: 1995-10-24
   Days after onset:7
Entered: 1995-11-20
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1405A / 3 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4A61037 / 3 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0723E / 3 MO / PO

Administered by: Public       Purchased by: Other
Symptoms: Brain oedema, Convulsion, Delirium, Grand mal convulsion, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-22
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hx szs, on medication
Allergies:
Diagnostic Lab Data: massive cerebral edema & sz;
CDC Split Type: TX95215

Write-up: mom called 17OCT95 & stated pt hadn run temp all noc up to 104.4 R, mom instructed to take pt to pvt MD, also to cont the APAP q 4-6hrs for the temp as instructed the day a/as per protocol; MD talked w/mom & also referred to pvt MD;


VAERS ID: 79263 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Texas  
Vaccinated:1995-07-18
Onset:0000-00-00
Submitted: 1995-08-09
Entered: 1995-11-20
   Days after submission:103
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4L51057 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1405A / 2 LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4L51057 / 1 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0716D / 1 MO / PO

Administered by: Other       Purchased by: Unknown
Symptoms: Apnoea, Cardiac arrest, Cyanosis, Dysphagia, Ecchymosis, Mydriasis, Skin discolouration, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-07-23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: no known allergies
Allergies:
Diagnostic Lab Data:
CDC Split Type: TX95193

Write-up: pt recvd vax & expired 5 days p/vax;11SEP95 hosp reported that ER notes state pt was DOA, pupils were fixed & dilated;skin was nottled;fontanelle was sunken;no bruises apparent;pt was intubated;dx cardiopulmonary arrest;questionable choking


VAERS ID: 79264 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Texas  
Vaccinated:1995-08-23
Onset:1995-08-23
   Days after vaccination:0
Submitted: 1995-08-23
   Days after onset:0
Entered: 1995-11-20
   Days after submission:89
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4B61114 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1164A / 2 LL / -
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 5G61029 / 1 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0721K / 1 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-08-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: Granulocytopenia
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: CBC
CDC Split Type: TX95185

Write-up: DOA hosp 23AUG95; 11SEP95 ER notes havd no addtl info nor do they know were, or if, an autopsy was performed;


VAERS ID: 79653 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Pennsylvania  
Vaccinated:1995-11-14
Onset:1995-11-19
   Days after vaccination:5
Submitted: 1995-11-22
   Days after onset:3
Entered: 1995-11-27
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428033 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1860A2 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 427357 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: nl past mortem exam
CDC Split Type:

Write-up: SIDS; pt found dead in crib


VAERS ID: 79656 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Ohio  
Vaccinated:1995-11-10
Onset:1995-11-13
   Days after vaccination:3
Submitted: 1995-11-14
   Days after onset:1
Entered: 1995-11-27
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429964 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1906A2 / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 427353 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Mylanta
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: autopsy pending
CDC Split Type:

Write-up: ? well 12NOV95; SIDS 13NOV95


VAERS ID: 79660 (history)  
Form: Version 1.0  
Age: 61.0  
Sex: Male  
Location: New York  
Vaccinated:1995-10-26
Onset:1995-10-27
   Days after vaccination:1
Submitted: 1995-11-09
   Days after onset:13
Entered: 1995-11-27
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES - / 2 - / IM

Administered by: Private       Purchased by: Private
Symptoms: Aspartate aminotransferase increased, Blood lactate dehydrogenase increased, Coma, Hepatic failure, Hepatic steatosis, Hyperglycaemia, Laboratory test abnormal, Right ventricular failure
SMQs:, Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Pulmonary hypertension (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-02
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Insulin, Accupril, APAP
Current Illness: none other than hypertension & diabetes
Preexisting Conditions: HTN, IDDM
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax 26OCT95;fever 102 27OCT followed by abd pain, vomiting, sweating;28OCT hosp ER T102;adm for hydration; BX 305; progressive liver failure, SGOT 544, LDH 5099; congestive heart failure, coma;autopsy massive faulty degen of liver


VAERS ID: 79601 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Utah  
Vaccinated:1995-11-03
Onset:1995-11-04
   Days after vaccination:1
Submitted: 1995-11-07
   Days after onset:3
Entered: 1995-11-28
   Days after submission:21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428039 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1664B2 / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. L0227 / 1 RL / SC

Administered by: Private       Purchased by: Private
Symptoms: Cyanosis, Stupor
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Dimetapp, APAP
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: baby found blue & unresponsive


VAERS ID: 79603 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1995-03-09
Onset:1995-03-09
   Days after vaccination:0
Submitted: 1995-11-20
   Days after onset:256
Entered: 1995-11-28
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 374962 / 1 - / -

Administered by: Private       Purchased by: Unknown
Symptoms: Agitation, Anorexia, Crying, Diarrhoea, Hypotonia, Pyrexia, Sudden infant death syndrome, Vomiting
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Depression (excl suicide and self injury) (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-03-16
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Acetominophen
Current Illness:
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: SIDS
CDC Split Type:

Write-up: high pitched persistant crying, fever, loss of appetite, throwing up, listlessness, loss of muscle control, diarrhea, shaking, death


VAERS ID: 79863 (history)  
Form: Version 1.0  
Age: 70.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1995-09-24
Onset:1995-09-25
   Days after vaccination:1
Submitted: 1995-12-01
   Days after onset:67
Entered: 1995-12-05
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E2835HA / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Malaise, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: ALI95493

Write-up: pt recvd flu vax & was observed x 30mins then sent home;@ the time of vax pt denied allergies;later that noc felt distressed & went to the ER dx sepsis was made;reporter states pt died that day p/being seen in ER;


VAERS ID: 81338 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: California  
Vaccinated:1979-09-10
Onset:0000-00-00
Submitted: 1994-11-03
Entered: 1995-12-06
   Days after submission:398
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH - / 1 MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Convulsion, Dementia, Hypokinesia, Mental retardation severity unspecified, Thinking abnormal
SMQs:, Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (narrow), Convulsions (narrow), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: none~ ()~~~In patient
Other Medications: unk
Current Illness: unk
Preexisting Conditions: unk
Allergies:
Diagnostic Lab Data:
CDC Split Type: 894314001K

Write-up: pt recvd vax & devel profound & permanent brain damage, motor impairment & learning disabilities;


VAERS ID: 79928 (history)  
Form: Version 1.0  
Age: 1.7  
Sex: Male  
Location: Ohio  
Vaccinated:1995-11-22
Onset:1995-11-22
   Days after vaccination:0
Submitted: 1995-12-05
   Days after onset:13
Entered: 1995-12-11
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DT: DT ADSORBED (NO BRAND NAME) / CONNAUGHT LABORATORIES 5F71080 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M005LP / 4 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 429326 / 3 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: febrile seizure JUL95
Allergies:
Diagnostic Lab Data: gross autospy-no finding;microscopic pending
CDC Split Type:

Write-up: death;pt vaxed 22NOV95 @ 1045-fever PM 22NOV95 no assoc sx was active & alert placed in bed 930PM on 23NOV95 found dead @ 1015PM was feb-past hx febrile seizure


VAERS ID: 79933 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: California  
Vaccinated:1995-11-29
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 1995-12-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429970 / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 428681 / UNK MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Injection site pain, Sudden infant death syndrome
SMQs:, Extravasation events (injections, infusions and implants) (broad), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-02
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: pt recvd Hep B vax 27OCT95 lot# 161489 by SKB
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: pt died of SIDS between 1130PM 1DEC & 6AM 2DEC-mom reported sore thigh @ inj site 29NOV then was fine on 30NOV;


VAERS ID: 79981 (history)  
Form: Version 1.0  
Age: 29.0  
Sex: Male  
Location: Illinois  
Vaccinated:1995-10-31
Onset:0000-00-00
Submitted: 1995-12-06
Entered: 1995-12-13
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. - / 1 - / -

Administered by: Other       Purchased by: Other
Symptoms: Alcohol intolerance, Arteriosclerosis, Cardiomyopathy, Myocardial infarction, Obesity, Overdose
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Drug abuse and dependence (broad), Cardiomyopathy (narrow), Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-03
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: alcoholism;
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES95110342

Write-up: pt recvd vax; 03nov95 pt died;autopsy showed that COD was acute myocardial infarction secondary to dilated cardiomyopathy;MD felt that pt''s demise was not related to hep B;


VAERS ID: 80138 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Washington  
Vaccinated:1995-11-29
Onset:1995-12-01
   Days after vaccination:2
Submitted: 1995-12-15
   Days after onset:14
Entered: 1995-12-19
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4E61115 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1288A / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M265LJ / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 726H6 / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Chills, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Aceteminophen gtts; Amoxicillin, Nystatin oral suspension
Current Illness: bronchitis,po thrush,rash,fever,rhinitis
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt came into hosp ER the morning of 01DEC95 DOA; probable SIDS; autopsy performed 1DEC95


VAERS ID: 80174 (history)  
Form: Version 1.0  
Age: 73.0  
Sex: Female  
Location: Illinois  
Vaccinated:1995-10-11
Onset:1995-10-15
   Days after vaccination:4
Submitted: 1995-12-18
   Days after onset:64
Entered: 1995-12-20
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 5F61099 / 2 - / -

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Pneumonia
SMQs:, Acute central respiratory depression (narrow), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-31
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: pneumonia 1 wk p/ 1994 flu vax;~ ()~~~In patient
Other Medications: numerous
Current Illness:
Preexisting Conditions: 5 yr hx of fibrotic lung disease,arteriosclrosis w/ renal angioplasy,carotid enarterectomy,stroke;living w/ husband as care giver;
Allergies:
Diagnostic Lab Data:
CDC Split Type: CO6416

Write-up: pt recvd vax; devel pneumonia & was hosp on ventilator assistance;died 31oct95;no autopsy performed;COD pneumonia & resp arrest;


VAERS ID: 80347 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Female  
Location: Florida  
Vaccinated:1995-10-23
Onset:1995-10-25
   Days after vaccination:2
Submitted: 1995-12-01
   Days after onset:37
Entered: 1995-12-27
   Days after submission:26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4C61144 / 2 LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1407A / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010LL / 2 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 072813 / 2 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Petechiae, Sudden infant death syndrome
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: determined SIDS by ME
CDC Split Type: FL95093

Write-up: SIDS death 25OCT95;


VAERS ID: 80766 (history)  
Form: Version 1.0  
Age:   
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 1996-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. E2715HA / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax; supposed death;


VAERS ID: 80811 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Oregon  
Vaccinated:1995-11-07
Onset:1995-11-30
   Days after vaccination:23
Submitted: 1995-12-14
   Days after onset:14
Entered: 1996-01-11
   Days after submission:28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4A61078 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1411A / 3 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4A61078 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0723F / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: autopsy report
CDC Split Type: OR9567

Write-up: SIDS-sudden infant death synd (crib death);


VAERS ID: 80841 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: New Hampshire  
Vaccinated:1995-08-04
Onset:1995-09-09
   Days after vaccination:36
Submitted: 1996-01-11
   Days after onset:124
Entered: 1996-01-16
   Days after submission:5
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4A61078 / 1 RL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1289A / 2 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4A61078 / 1 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0716M / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Injury, Sudden infant death syndrome
SMQs:, Accidents and injuries (narrow), Hostility/aggression (broad), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-09-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: none known
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type: NH95031

Write-up: pt recvd vax; SIDS 9sep95;


VAERS ID: 80845 (history)  
Form: Version 1.0  
Age: 0.52  
Sex: Male  
Location: Georgia  
Vaccinated:1995-12-11
Onset:1995-12-11
   Days after vaccination:0
Submitted: 1995-12-20
   Days after onset:9
Entered: 1996-01-16
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 394956 / 3 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0213A / 3 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0720B / 3 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Cardiac arrest, Hypokinesia, Pyrexia, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-16
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA95200

Write-up: pt recvd vax;T 103;apap given;baby put to sleep;when father came, noticed pt not moving;began CPR;to hosp;pt died due to SIDS;father blames himself for pt death;no evidence of neglect or abuse from PAR per reporter;


VAERS ID: 80847 (history)  
Form: Version 1.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated:1995-11-01
Onset:1995-11-01
   Days after vaccination:0
Submitted: 1995-11-01
   Days after onset:0
Entered: 1996-01-16
   Days after submission:76
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 5F61162 / UNK LA / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Asthma, Pyrexia, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-10
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: none
Preexisting Conditions: pcn, demedrol, codeine,tape, beesting
Allergies:
Diagnostic Lab Data:
CDC Split Type: KS95057

Write-up: pt recvd vax;T 100; wheezing 3nov95; emesis; apap given; to er;


VAERS ID: 80949 (history)  
Form: Version 1.0  
Age: 1.3  
Sex: Male  
Location: Connecticut  
Vaccinated:1996-01-11
Onset:1996-01-15
   Days after vaccination:4
Submitted: 1996-01-15
   Days after onset:0
Entered: 1996-01-18
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HIBV: HIB (HIBTITER) / PFIZER/WYETH M265L5 / 4 RL / -
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1320A / 1 LL / -

Administered by: Private       Purchased by: Private
Symptoms: Chills, Diarrhoea, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: EMTS w/ lividity & rigor
CDC Split Type:

Write-up: pt recvd vax 11JAN96 & exp emesis on 11JAN;well 12JAN;14NOV diarrhea stool;put to bed 14NOV & found DOA 7AM 15NOV by parents;


VAERS ID: 80976 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: Illinois  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 1996-01-11
Entered: 1996-01-22
   Days after submission:11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. - / 2 - / IM

Administered by: Other       Purchased by: Other
Symptoms: Drug ineffective, Dyspnoea, Infection, Respiratory disorder
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: pt recvd 1st dose HEP B vax 3OCT94;
Current Illness:
Preexisting Conditions: premature infant
Allergies:
Diagnostic Lab Data: AUG95 HBsAg 0.439; HBsAg 0.314; 12OCT95 HBsAg 0.0; Hep C antibody neg;
CDC Split Type: WAES96010161

Write-up: pt recvd 2nd dose of vax & several days later pt died d/t resp complications;lab eval upon autopsy in AUG95 revealed hepatitis B surface antigen 0.439 & 0.314;specimen was sent by the coroner''s office to a blood bank for further testing;


VAERS ID: 81270 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: California  
Vaccinated:1996-01-09
Onset:1996-01-15
   Days after vaccination:6
Submitted: 1996-01-17
   Days after onset:2
Entered: 1996-01-24
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 427839 / 1 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0863B / 2 LL / SC
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0724C / 1 MO / PO

Administered by: Private       Purchased by: Other
Symptoms: Apnoea, Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: APAP;Triviflor;Dimetapp
Current Illness: mild cough
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: full arrest @ home, CPR started, taken to hosp;full code gave, pronounced expired @ 2229;


VAERS ID: 81461 (history)  
Form: Version 1.0  
Age: 74.0  
Sex: Female  
Location: Connecticut  
Vaccinated:1995-11-16
Onset:1995-11-19
   Days after vaccination:3
Submitted: 1996-01-16
   Days after onset:58
Entered: 1996-01-30
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH - / UNK - / IM

Administered by: Private       Purchased by: Private
Symptoms: Asthenia, Mouth ulceration
SMQs:, Severe cutaneous adverse reactions (broad), Systemic lupus erythematosus (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: urinary tract infect
Preexisting Conditions: pt may have been taking Macrodantin for a urinary tract infect @ the time of death
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896017020L

Write-up: pt recvd vax 16NOV95;19NOV95 noted general weakness & canker sore in mouth;notified MD but declined to go to office because of weakness;next day husband found pt dead;


VAERS ID: 81465 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Tennessee  
Vaccinated:1995-12-04
Onset:1995-12-05
   Days after vaccination:1
Submitted: 1996-01-24
   Days after onset:50
Entered: 1996-01-30
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429970 / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 428679 / UNK MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Sudden infant death syndrome
SMQs:, Acute central respiratory depression (narrow), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy consistent w/SIDS
CDC Split Type:

Write-up: pt was fed morning p/vax & when mom checked on pt was found to not be breathing;autopsy=SIDS


VAERS ID: 81739 (history)  
Form: Version 1.0  
Age: 70.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:1995-06-07
Onset:1995-06-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 1996-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
TD: TD ADSORBED (TDVAX) / MASS. PUB HLTH BIOL LAB TD54 / UNK LA / SC

Administered by: Private       Purchased by: Other
Symptoms: Apnoea, Coma, Convulsion, Encephalopathy, Hypoxia
SMQs:, Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Chronic kidney disease (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-07-12
   Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Pred, Serevant, Volmax, Cromolyn, Ventolin
Current Illness: COPD, skin infect
Preexisting Conditions: allergies: Tolectin, Clinoril, shellfish
Allergies:
Diagnostic Lab Data: severe alpha coma by EEG
CDC Split Type:

Write-up: 7JUN95 pt was treated for infected skin abrasion;in later AM was given Cephalexin & a Td booster;215PM pt was found to be convulsing & apneic;pt admitted to hosp & found to have severe anoxic encephalopathy & expired 12JUL95


VAERS ID: 81866 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Ohio  
Vaccinated:1996-01-04
Onset:1996-01-22
   Days after vaccination:18
Submitted: 1996-01-30
   Days after onset:8
Entered: 1996-02-05
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428038 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0723H / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Petechiae, Pulmonary oedema, Stupor, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: pt recvd Hep B vax by MSD lot# 1358A on 30NOV95
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: OH96011

Write-up: sudden infant death synd died 22JAN96;


VAERS ID: 82014 (history)  
Form: Version 1.0  
Age: 0.7  
Sex: Male  
Location: Maryland  
Vaccinated:1995-12-29
Onset:1995-12-30
   Days after vaccination:1
Submitted: 1996-01-15
   Days after onset:16
Entered: 1996-02-07
   Days after submission:23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428039 / 3 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1965A2 / 3 RL / IM

Administered by: Private       Purchased by: Private
Symptoms: Conjunctivitis, Coronary artery disease, Infection, Mucous membrane disorder, Pyrexia, Somnolence, Vascular anomaly, Vasculitis
SMQs:, Severe cutaneous adverse reactions (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Congenital, familial and genetic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Other ischaemic heart disease (narrow), Vasculitis (narrow), Conjunctival disorders (narrow), Ocular infections (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Augmentin suspension
Current Illness: ear infect
Preexisting Conditions: pt was being treated w/Augmentin for ear infect
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896017016L

Write-up: pt recvd vax 29DEC95 & 3JAN96 pt devel fever of 103.4;seen in MD office the next day w/fever of 105 & listlessness;dx @ that time w/conjunctivitis & viral synd;pt adm to hosp w/in next several days peds cardiologist dx kawasaki''s disease;


VAERS ID: 82176 (history)  
Form: Version 1.0  
Age: 63.0  
Sex: Male  
Location: Kansas  
Vaccinated:1996-01-30
Onset:1996-01-31
   Days after vaccination:1
Submitted: 1996-02-05
   Days after onset:5
Entered: 1996-02-08
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / SMITHKLINE BEECHAM - / 1 - / -

Administered by: Public       Purchased by: Unknown
Symptoms: Abscess, Delirium, Dyspnoea, Hepatic function abnormal, Hepatitis, Jaundice, Pyrexia, Renal failure, Thrombocytopenia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Cholestasis and jaundice of hepatic origin (narrow), Hepatitis, non-infectious (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (narrow), Biliary tract disorders (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Dehydration (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 51 days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: CO6460

Write-up: hospitalized w/fever 103;tx & temp D/C 1FEB96 AM,temp up to 104;HD has no addl info;2FEB96 blood test indicated elevated enzymes;


VAERS ID: 82237 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: Hawaii  
Vaccinated:1995-11-24
Onset:1995-11-26
   Days after vaccination:2
Submitted: 1996-02-02
   Days after onset:68
Entered: 1996-02-09
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4E61015 / UNK LL / -
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4E61015 / 2 LL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 428690 / UNK - / -

Administered by: Public       Purchased by: Public
Symptoms: Cardiac arrest, Stupor, Unevaluable event
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NA~ ()~~~In patient
Other Medications: NONE
Current Illness: mild cough
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Code lab-autopsy
CDC Split Type: HI9601

Write-up: pt recvd vax 24NOV95 & was sleeping w/father & found pulseless & unresponsive;brought to ER & pronounced dead;autopsy done conclusion accidental suffocation as COD


VAERS ID: 82320 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Wisconsin  
Vaccinated:1995-07-24
Onset:1995-08-17
   Days after vaccination:24
Submitted: 1995-09-06
   Days after onset:20
Entered: 1996-02-12
   Days after submission:159
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428037 / 1 LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0447A / 2 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 426338 / 1 MO / PO

Administered by: Private       Purchased by: Other
Symptoms: Apnoea, Asphyxia, Cardiac arrest, Cyanosis, Haemorrhage, Lung disorder, Stupor, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-08-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: WI95055

Write-up: no adverse events noted;pt died on 17AUG95 report filed as w/in 1mo of vax;pt''s case is being treated as SIDS;


VAERS ID: 82520 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Massachusetts  
Vaccinated:1996-01-29
Onset:1996-01-30
   Days after vaccination:1
Submitted: 1996-01-30
   Days after onset:0
Entered: 1996-02-14
   Days after submission:15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / MASS. PUB HLTH BIOL LAB DTP292 / 1 - / IM L
HIBV: HIB (HIBTITER) / PFIZER/WYETH MO15LL / 1 - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 725A4 / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: premature baby born to mom who used cocaine during pregnancy
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax 3PM 29JAN96;7AM on 30JAN pt was found in full cardiopulmonary arrest by mother;911 called;attempts to revise failed;pt DOA @ ER:


VAERS ID: 82670 (history)  
Form: Version 1.0  
Age: 60.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:1995-10-18
Onset:1996-02-07
   Days after vaccination:112
Submitted: 1996-02-12
   Days after onset:5
Entered: 1996-02-16
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES 5F61134 / UNK LA / IM

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Asthenia, Guillain-Barre syndrome, Malaise, Paraesthesia, Rhinitis
SMQs:, Peripheral neuropathy (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Respiratory failure (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 3FEB96 rhinitis x 3 days;7FEB96 numbness in hands & feet;seen in ER inc numbness & fatigue,malaise-presently dx w/GBS on a ventilator;


VAERS ID: 82736 (history)  
Form: Version 1.0  
Age: 4.0  
Sex: Male  
Location: Maryland  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 1995-02-15
Entered: 1996-02-20
   Days after submission:370
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Clostridium colitis, Infection, Thrombocytopenic purpura
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Pseudomembranous colitis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no relevant data
CDC Split Type: WAES96020134

Write-up: pt recvd vax;devel thrombocytopenic purpura;exp also an acute onset of escherichia coli 0157:H7 infection complicated by pseudomembranous colitis;died 7 days following vax;


VAERS ID: 83118 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Virginia  
Vaccinated:1996-02-09
Onset:1996-02-19
   Days after vaccination:10
Submitted: 1996-02-21
   Days after onset:2
Entered: 1996-02-27
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 428033 / 1 RL / -
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1967A2 / 2 LL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 427354 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Bronchitis, Nervousness, Petechiae, Pyrexia, Sudden infant death syndrome
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-19
   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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: t101R,irritable 48hrs p/vax 6PM 11FEB96;DTP-became sx free;found dead at babysitters 19FEB96;


VAERS ID: 83450 (history)  
Form: Version 1.0  
Age:   
Sex: Unknown  
Location: Kansas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 1996-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: no relevant data
CDC Split Type: WAES95010821

Write-up: pt recvd vax & died subsequently;


VAERS ID: 83462 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Tennessee  
Vaccinated:1996-02-22
Onset:1996-02-23
   Days after vaccination:1
Submitted: 1996-02-26
   Days after onset:3
Entered: 1996-03-05
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 431965 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1948A2 / 1 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0735K / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cyanosis
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: complex congenital heart disease s/p rt blalock-taunseig shunt
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was found blue, not breathing in crib;pt was rushed to ER where resuscitation performed to no avail


VAERS ID: 83552 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Georgia  
Vaccinated:1996-01-29
Onset:0000-00-00
Submitted: 1996-02-05
Entered: 1996-03-11
   Days after submission:35
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4E61116 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0213A / 1 RL / IM
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 4F61046 / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0729N / 1 MO / PO

Administered by: Public       Purchased by: Other
Symptoms: Acidosis, Apnoea, Arrhythmia, Cardiac arrest, Cyanosis, Hypotonia, Mydriasis, Respiratory disorder
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Lactic acidosis (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (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), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-02
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: paralyzed vocal cords trach, gastrostomytube/aspiration cardia arrest no post
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA96010

Write-up: no reactions


VAERS ID: 83553 (history)  
Form: Version 1.0  
Age: 82.0  
Sex: Female  
Location: Georgia  
Vaccinated:1995-10-27
Onset:1995-10-29
   Days after vaccination:2
Submitted: 1995-11-01
   Days after onset:3
Entered: 1996-03-11
   Days after submission:131
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4958139 / 3 RA / IM

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Myocardial infarction
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-10-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: arhtritis
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA96001

Write-up: deceased 28OCT95


VAERS ID: 83615 (history)  
Form: Version 1.0  
Age:   
Sex: Male  
Location: California  
Vaccinated:1996-02-26
Onset:1996-02-26
   Days after vaccination:0
Submitted: 1996-02-29
   Days after onset:3
Entered: 1996-03-12
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1196B / 1 RL / IM

Administered by: Private       Purchased by: Private
Symptoms: Infection, Pyrexia, Sudden infant death syndrome
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-28
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: rt facial nerve palsy, congenital fracture rt clavicle
Allergies:
Diagnostic Lab Data: BC 26FEB staph sinulans; 27FEB BC sterile;
CDC Split Type:

Write-up: temp elevation to approx 102,lasting about 15mins each time PM 26FEB,AM 27FEB & 2AM 28FEB;26FEB BC-staph sinulans;27FEB BC sterile;no other sx until sudden death 28FEB96 2PM;


VAERS ID: 83660 (history)  
Form: Version 1.0  
Age: 0.15  
Sex: Male  
Location: Oklahoma  
Vaccinated:1996-01-25
Onset:0000-00-00
Submitted: 1996-01-26
Entered: 1996-03-14
   Days after submission:48
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429965 / 1 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0898B / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 735M6 / 1 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Petechiae, Stupor, Sudden infant death syndrome
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Neonatal disorders (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-01-25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: polytrim opth drops
Current Illness: plugged tear duct nasal cong
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was given vax 24JAN96 @ approx 1020AM office was notified 25JAN96 approx 10AM by the medical examiners office that pt died on 24JAN96 in the evening;@ this time it is unclear the COD


VAERS ID: 83687 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Female  
Location: Virginia  
Vaccinated:1995-12-19
Onset:1995-12-22
   Days after vaccination:3
Submitted: 1996-03-11
   Days after onset:80
Entered: 1996-03-15
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 429972 / 3 RL / -

Administered by: Private       Purchased by: Other
Symptoms: Sudden infant death syndrome, Unevaluable event
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-22
   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: NONE
Current Illness: cold & teething
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death-75 hrs p/the receipt of the DTP vax


VAERS ID: 83690 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Washington  
Vaccinated:1996-02-14
Onset:1996-02-14
   Days after vaccination:0
Submitted: 1996-02-15
   Days after onset:1
Entered: 1996-03-15
   Days after submission:29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4E61115 / 2 RL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M305LK / 2 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0726K / 2 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Cardiac arrest, Haemorrhage, Hepatic steatosis, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type: WA961209

Write-up: pt taken to hosp ER @ approx 11PM for resp failure


VAERS ID: 83744 (history)  
Form: Version 1.0  
Age: 0.1  
Sex: Male  
Location: Illinois  
Vaccinated:1996-03-07
Onset:1996-03-09
   Days after vaccination:2
Submitted: 1996-03-12
   Days after onset:3
Entered: 1996-03-19
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0524B / 2 LA / IM

Administered by: Private       Purchased by: Other
Symptoms: Infection, Pulmonary oedema
SMQs:, Cardiac failure (narrow), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-09
   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: none
Preexisting Conditions: cocaine baby; ward of state at birth;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax;well baby in for routine checkup,vitals ok,noted nasal stuffiness;


VAERS ID: 84030 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: California  
Vaccinated:1996-03-06
Onset:1996-03-07
   Days after vaccination:1
Submitted: 1996-03-18
   Days after onset:11
Entered: 1996-03-27
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429973 / 1 RL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1963A2 / 2 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0733E / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Pulmonary oedema, Stupor, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-07
   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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: none by MD-coroners case
CDC Split Type:

Write-up: pt recvd vax 6MAR96 & mom stated no problems;fed pt @ 5AM on 7MAR96;checked pt @ 7AM & found dead


VAERS ID: 84075 (history)  
Form: Version 1.0  
Age: 2.0  
Sex: Female  
Location: Kansas  
Vaccinated:1996-02-09
Onset:1996-02-15
   Days after vaccination:6
Submitted: 1996-02-16
   Days after onset:1
Entered: 1996-03-29
   Days after submission:42
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429971 / 4 LL / IM

Administered by: Public       Purchased by: Public
Symptoms: Apnoea, Bronchitis, Cardiac arrest, Pleural effusion, Pneumonia, Pulmonary oedema
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-15
   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: imuran, cyclosporin
Current Illness: none
Preexisting Conditions: asplenic since birth; heart transplant 12jul95;
Allergies:
Diagnostic Lab Data:
CDC Split Type: KS96008

Write-up: pt recv vax;grandfather noticed that "she did not look good". CPR was started & Emergency team called & pt transferred to hosp;


VAERS ID: 84303 (history)  
Form: Version 1.0  
Age: 20.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:1992-09-03
Onset:0000-00-00
Submitted: 1996-03-29
Entered: 1996-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: Unknown
Symptoms: Abdominal pain, Drug ineffective, Infection, Laboratory test abnormal, Lung disorder, Pleural effusion, Pneumonia, Pyrexia
SMQs:, Acute pancreatitis (broad), Lack of efficacy/effect (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Omeprazole, Bactrim, Fluconazole, Clarithromyan;
Current Illness:
Preexisting Conditions: mild hemophilia A, recvd factor vIII x 1, AIDS, hx pneumocystis carinii pneumonia OCT92; allergic to PCN
Allergies:
Diagnostic Lab Data: CD4=<10 for over 1 year; CXR ABN; abdom CT, ERCP;COD progressive pulmonary dz w/bilat pleural effusions
CDC Split Type:

Write-up: adm to hosp 31AUG95 w/3wk hx progressive non prod cough,SOB & fevers;devel abd pain,diarrhea;lost 30lbs;pt had multiple diagnostic studies,devel pleural effusion,viral pneumonia & measles pneumonia;


VAERS ID: 84211 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Ohio  
Vaccinated:1996-03-04
Onset:0000-00-00
Submitted: 1996-03-20
Entered: 1996-04-01
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429321 / 1 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0896B / 2 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0730C / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NA
Current Illness: NONE
Preexisting Conditions: NKA
Allergies:
Diagnostic Lab Data: unk
CDC Split Type: OH96039

Write-up: pt had no adverse rxn to vax reported ever;report being submitted only because child died on 17MAR96;case sensitive d/t death mom not contacted regarding cause;death certificate states COD SIDS;


VAERS ID: 84550 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Kansas  
Vaccinated:1995-12-19
Onset:1996-03-07
   Days after vaccination:79
Submitted: 1996-04-01
   Days after onset:25
Entered: 1996-04-05
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1949A2 / 2 RL / IM

Administered by: Other       Purchased by: Unknown
Symptoms: Drug ineffective, Hepatitis, Infection, Petechiae, Pulmonary oedema, Sudden infant death syndrome, Vasodilatation
SMQs:, Cardiac failure (narrow), Hepatitis, non-infectious (narrow), Lack of efficacy/effect (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Albuterol
Current Illness:
Preexisting Conditions: resp syncytial virus
Allergies:
Diagnostic Lab Data: HBSAN 7MAR96 positive; liver function tests 7MAR96 nl;
CDC Split Type: 960042691

Write-up: pt recv vax 19DEC95 & COD w/ruled sudden infant death synd by the coroner;a blood test taken @ the autopsy revealed a positive hepatitis B surface antigen;There is no family hx of hepatitis;early infect-poss false positive;


VAERS ID: 84630 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Arizona  
Vaccinated:1996-03-27
Onset:1996-03-29
   Days after vaccination:2
Submitted: 1996-03-29
   Days after onset:0
Entered: 1996-04-08
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 5H61047 / 1 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M005LN / 1 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0728M / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Pneumonia, Sudden infant death syndrome
SMQs:, Eosinophilic pneumonia (broad), Neonatal disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: URI
Preexisting Conditions: prematurity/RDS
Allergies:
Diagnostic Lab Data:
CDC Split Type: AZ9607

Write-up: pt recv vax 27MAR96 & mom found baby dead 29MAR96;


VAERS ID: 84670 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Female  
Location: New York  
Vaccinated:1996-02-12
Onset:1996-02-12
   Days after vaccination:0
Submitted: 1996-04-02
   Days after onset:50
Entered: 1996-04-09
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 428062 / 2 - / L
HIBV: HIB (HIBTITER) / PFIZER/WYETH M005LP / 2 - / L

Administered by: Private       Purchased by: Other
Symptoms: Apnoea, Cardiac arrest, Cerebral haemorrhage, Cerebral ischaemia, Convulsion, Delirium, Hypoxia, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Neonatal disorders (narrow), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1996-03-13
   Days after onset: 30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 21 days
   Extended hospital stay? Yes
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: congestion
Preexisting Conditions: pt was born premature @ 29wks gestation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax 12FEB96 & the same day became irritable,sleepy & sl fever,given APAP;sx cont & 19FEB96 pt was found in crib w/SOB;pt died on 13MAR96;hosp x 3 wk;pt had numerous episodes of sz,edema,blood in brian-declared brain dead 22FE;


VAERS ID: 84679 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: South Carolina  
Vaccinated:1996-02-16
Onset:0000-00-00
Submitted: 1996-02-20
Entered: 1996-04-11
   Days after submission:50
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429968 / 1 LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1399A / 2 RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 428485 / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Apnoea, Chills
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications:
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax 16FEB96 & to ER p/discovered by mom or grandma to be cold & not breathing;DOA by ER MD 18FEB96;


VAERS ID: 84790 (history)  
Form: Version 1.0  
Age: 0.51  
Sex: Female  
Location: Florida  
Vaccinated:1996-03-05
Onset:0000-00-00
Submitted: 1996-03-21
Entered: 1996-04-15
   Days after submission:24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429965 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1189B / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0729H / 1 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Cardiac arrest, Vasodilatation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: lt OM; upper resp infect
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: death certificate is pending histology and cultures (16-20 weeks)
CDC Split Type: FL96018

Write-up: no known adverse rxn to vax;pt was seen twice in the clinic & was gaining weight & developmentally WNL;visit of 25JAN96 weight 13# 13oz seen for bronchiolitis & OM;5MAR96 seen for OM & Upper resp infect weight 14# 5oz


VAERS ID: 85030 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Maryland  
Vaccinated:1996-03-25
Onset:0000-00-00
Submitted: 1996-04-08
Entered: 1996-04-22
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 433363 / 1 RL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1967A2 / 2 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 430190 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-04-04
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: pt recvd hep B vax lot# 1967A2 23FEB96;
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: SIDS


VAERS ID: 85080 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Maryland  
Vaccinated:1996-04-19
Onset:1996-04-20
   Days after vaccination:1
Submitted: 1996-04-20
   Days after onset:0
Entered: 1996-04-23
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 429975 / 1 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M805LP / UNK LL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 428489 / UNK MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Chills, Coma, Cyanosis
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy to be performed
CDC Split Type:

Write-up: 19hrs p/vax pt found unresponsive, cold & blue;pt unable to be resuscitated


VAERS ID: 85216 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Male  
Location: Arkansas  
Vaccinated:1995-12-06
Onset:1995-12-22
   Days after vaccination:16
Submitted: 1996-03-25
   Days after onset:94
Entered: 1996-04-24
   Days after submission:29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4E61024 / 2 RL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1359A / 3 LL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4E61024 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 072HL / 2 MO / PO

Administered by: Public       Purchased by: Other
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-12-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type: AR9617

Write-up: no known COD-death certificate pending to r/o SIDS


VAERS ID: 85217 (history)  
Form: Version 1.0  
Age: 1.1  
Sex: Male  
Location: Arkansas  
Vaccinated:1996-02-29
Onset:1996-03-08
   Days after vaccination:8
Submitted: 1996-03-25
   Days after onset:17
Entered: 1996-04-24
   Days after submission:29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429965 / 4 RL / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0887D / 1 LA / SC

Administered by: Public       Purchased by: Other
Symptoms: Apnoea, Bronchitis
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: ATB
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: info recv for death certificate that pt had a resp arrest & acute bronchitis;parents refused autopsy according to funeral director


VAERS ID: 85372 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1996-02-22
Onset:1996-02-22
   Days after vaccination:0
Submitted: 1996-03-12
   Days after onset:19
Entered: 1996-04-29
   Days after submission:47
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 431966 / 1 LL / -

Administered by: Public       Purchased by: Public
Symptoms: Agitation, Petechiae, Skin discolouration, Stupor, Sudden infant death syndrome
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: post mortem consistent w/SIDS;toxicology pending;no abnormalities described by pathologist
CDC Split Type: PA9613

Write-up: pt started crying 8PM & wouldn''t stop;pt changed color;911 called paramedics worked on pt for 30mins & then went to hosp;pt was reported dying, then dead;autopsy requested;


VAERS ID: 85376 (history)  
Form: Version 1.0  
Age: 0.1  
Sex: Male  
Location: California  
Vaccinated:1996-04-18
Onset:1996-04-19
   Days after vaccination:1
Submitted: 1996-04-22
   Days after onset:3
Entered: 1996-04-29
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 5H61047 / 1 - / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 1944A2 / 2 - / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 5H61156 / 1 - / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. K1016 / 1 - / SC

Administered by: Private       Purchased by: Public
Symptoms: Sudden infant death syndrome, Unevaluable event
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was found dead in crib on 19APR96;pt recv vax 18APR96;pt was laid on belly to sleep


VAERS ID: 85549 (history)  
Form: Version 1.0  
Age: 0.7  
Sex: Female  
Location: Illinois  
Vaccinated:1996-04-18
Onset:1996-04-19
   Days after vaccination:1
Submitted: 1996-04-24
   Days after onset:5
Entered: 1996-05-06
   Days after submission:12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 433363 / 2 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 431266 / 2 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Stupor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: none~ ()~~~In patient
Other Medications:
Current Illness: otitis med
Preexisting Conditions: mild motor delay
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax&was found unresponsive next am;to hosp where pt pronounced dead;


VAERS ID: 85550 (history)  
Form: Version 1.0  
Age: 15.0  
Sex: Male  
Location: Minnesota  
Vaccinated:1996-02-19
Onset:1996-03-20
   Days after vaccination:30
Submitted: 1996-04-29
   Days after onset:39
Entered: 1996-05-06
   Days after submission:7
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 0441B / 1 - / SC

Administered by: Other       Purchased by: Other
Symptoms: Cardiac arrest, Drug ineffective, Infection, Pneumonia, Renal failure, Respiratory disorder, Sepsis, Shock
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Lack of efficacy/effect (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-31
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Anticonvuls, nos;
Current Illness:
Preexisting Conditions: mental retardation;sz;quadriplegia,spastic;microcephaly;pneumonia,aspiration;tracheostomy;thrombocytopenia; infect,yeast;Palsy,cerebral;
Allergies:
Diagnostic Lab Data: platelet count thrombocytopenia;culture :lesions pos for varicella;culture : trachea-enterobacteriaceae;
CDC Split Type: WAES96041438

Write-up: pt recv vax;exp inc resp rate&seen by MD;appeared to be in shock;maculopapular rash;to hosp;lab showed dec platelets&pneumonia;vesicles found to be varicella zoster;was fluid resuscitated&tx w/ atbs;culture of trachea pos;resp fail


VAERS ID: 85553 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Female  
Location: Georgia  
Vaccinated:1996-03-29
Onset:1996-04-04
   Days after vaccination:6
Submitted: 1996-04-09
   Days after onset:4
Entered: 1996-05-06
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 433567 / 3 - / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 08948 / UNK - / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0739M / 3 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896103003L

Write-up: pt recv vax; died & COD was stated as SIDS;


VAERS ID: 85554 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Ohio  
Vaccinated:1996-04-08
Onset:1996-04-09
   Days after vaccination:1
Submitted: 1996-04-09
   Days after onset:0
Entered: 1996-05-06
   Days after submission:27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429321 / 1 - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0730C / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Hypothermia, Petechiae, Salivary hypersecretion, Sudden infant death syndrome, Unevaluable event
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Accidents and injuries (broad), Cardiomyopathy (broad), Neonatal disorders (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness: none stated
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: autopsy pending
CDC Split Type: 896103002L

Write-up: pt recv vax;found dead in bed;autopsy pending


VAERS ID: 85972 (history)  
Form: Version 1.0  
Age: 0.6  
Sex: Female  
Location: New Hampshire  
Vaccinated:1995-10-23
Onset:1995-11-14
   Days after vaccination:22
Submitted: 1996-02-21
   Days after onset:99
Entered: 1996-05-13
   Days after submission:81
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 4A6140 / 3 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 4A6140 / 3 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0725C / 3 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Oedema, Petechiae, Pulmonary oedema, Sudden infant death syndrome
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: APAP
Current Illness: mild URI vs teething sx/afeb
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: Autopsy consistent w/SIDS death
CDC Split Type: NH96008

Write-up: pt died of SIDS


VAERS ID: 86193 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Tennessee  
Vaccinated:1996-04-25
Onset:1996-04-26
   Days after vaccination:1
Submitted: 1996-05-03
   Days after onset:7
Entered: 1996-05-20
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 429969 / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1198B / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0726E / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Lung disorder, Petechiae, Sudden infant death syndrome, Unevaluable event
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: none x/sl cough
Preexisting Conditions: vaccine delayed until pt reached 10 pounds-mom stated over 10 pounds 25APR
Allergies:
Diagnostic Lab Data: autopsy done-no results received
CDC Split Type: TN96045

Write-up: pt recv vax 2PM-3PM 25APR96-pt presented in good hlth-sl cough but chest clear to auscultation-mom stated no fever in last 48hr;this was pt 1st immun w/no adverse changes noted in clinic;mom states pt fine&put to bed-found dead in bed


VAERS ID: 86283 (history)  
Form: Version 1.0  
Age: 6.0  
Sex: Male  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 1996-05-20
Entered: 1996-05-23
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 0178A / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No relevant data;
CDC Split Type: WAES96050726

Write-up: pt recv vax & shortly afterward pt exp a rapidly deteriorating condition & was hosp;pt died;COD was not reported;


VAERS ID: 86285 (history)  
Form: Version 1.0  
Age: 71.0  
Sex: Male  
Location: Florida  
Vaccinated:1995-12-18
Onset:1995-12-19
   Days after vaccination:1
Submitted: 1996-01-02
   Days after onset:14
Entered: 1996-05-23
   Days after submission:141
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH - / UNK - / IM

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cardiac arrest, Coma, Hypoventilation, Infection, Renal failure acute, Sepsis, Shock
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1995-12-23
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness: NONE
Preexisting Conditions: pt was reportedly completely well prior to vax;
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896005015L

Write-up: pt recv vax 18DEC95&next day became ill;pt hosp in a comatose state&placed on a ventilator;pt died next day;death allegedly d/t skin infect;death certificate stated COD cardiac arrest,assoc w/sepsis,shock,acute renal failure,resp failure


VAERS ID: 86401 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: Pennsylvania  
Vaccinated:1996-05-23
Onset:1996-05-23
   Days after vaccination:0
Submitted: 1996-05-23
   Days after onset:0
Entered: 1996-05-29
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 433363 / 2 LL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0737C / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Otitis media, Petechiae, Sudden infant death syndrome
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-05-23
   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: none
Current Illness: none
Preexisting Conditions: PROM at birth, recvd geitajini
Allergies:
Diagnostic Lab Data: none
CDC Split Type:

Write-up: pt recv vax; died w/in 24 hrs; found dead at home;


VAERS ID: 86649 (history)  
Form: Version 1.0  
Age: 73.0  
Sex: Male  
Location: Maryland  
Vaccinated:1995-11-27
Onset:1995-11-29
   Days after vaccination:2
Submitted: 1996-02-05
   Days after onset:68
Entered: 1996-06-03
   Days after submission:118
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4958066 / 2 LA / IM

Administered by: Private       Purchased by: Private
Symptoms: Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1995-11-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Benazepril HCL;Felodipine;
Current Illness:
Preexisting Conditions: pt had carcinoma of the colon which was resected 2NOV95;no hx of heart disease in pt or family
Allergies:
Diagnostic Lab Data:
CDC Split Type: 896038023L

Write-up: pt recv vax & 2 days later pt did not feel well & went to bed;pt died in sleep;no hx/evidence that pt exp heart arrhythmia, chest discomfort, fatigue or weakness during the interval between vax & death;no autopsy performed;COD unk;


VAERS ID: 86560 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: Georgia  
Vaccinated:1996-04-04
Onset:0000-00-00
Submitted: 1996-05-13
Entered: 1996-06-04
   Days after submission:22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 390952 / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0729M / 1 MO / PO

Administered by: Public       Purchased by: Other
Symptoms: Infection, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: purple cold med;
Current Illness: past cold
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA96058

Write-up: pt recv vax; mom reported child died 11apr96 from pneumonia;


VAERS ID: 86609 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Louisiana  
Vaccinated:1996-05-17
Onset:1996-05-21
   Days after vaccination:4
Submitted: 1996-05-22
   Days after onset:1
Entered: 1996-06-05
   Days after submission:14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / CONNAUGHT LABORATORIES 5H61118 / 1 LA / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 1197B / 2 RA / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 5H61047 / 1 LA / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0735C / 1 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Hepatocellular damage, Petechiae, Pulmonary oedema, Pyrexia, Renal impairment, Spleen disorder, Sudden infant death syndrome
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Neonatal disorders (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-05-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: rt OM;rt nasal congestion;poss early pne
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy done 22MAY96-showed SIDS was COD
CDC Split Type: LA960601

Write-up: mom reports pt was congested;began running temp of 101 17MAY96;Saturday AM temp was 101-102 Monday temp was 99 Tuesday AM temp was 103 66AM & dec w/pediatric APAP;


VAERS ID: 86793 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: New Hampshire  
Vaccinated:1996-02-14
Onset:1996-03-12
   Days after vaccination:27
Submitted: 1996-03-12
   Days after onset:0
Entered: 1996-06-07
   Days after submission:86
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 427840 / 1 - / IM L
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0729B / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Bronchitis, Infection, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: Bactrim
Current Illness: resolving OM
Preexisting Conditions: resp syncytial virus 31JAN96
Allergies:
Diagnostic Lab Data:
CDC Split Type: NH96013

Write-up: death on 25th day post vax;autopsy dx broncho-pneumonia;


VAERS ID: 86882 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Georgia  
Vaccinated:1996-05-15
Onset:1996-05-21
   Days after vaccination:6
Submitted: 1996-05-21
   Days after onset:0
Entered: 1996-06-11
   Days after submission:21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 394956 / 2 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0737H / 2 MO / PO

Administered by: Public       Purchased by: Public
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: GA96065

Write-up: coroner called hlth dept to report death-COD SIDS;death certificate requested from RCHD;


VAERS ID: 86930 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: California  
Vaccinated:1996-05-16
Onset:1996-05-16
   Days after vaccination:0
Submitted: 1996-05-22
   Days after onset:6
Entered: 1996-06-13
   Days after submission:22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 43019 / 1 - / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0834B / 1 - / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH M010LP / 1 - / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0738F / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Agitation, Apnoea, Cardiac arrest, Pallor, Stupor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-05-16
   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: Tylenol
Current Illness: afeb-mild URI
Preexisting Conditions: rubinstain taybi sy;hypoplastic lt heart ventricle
Allergies:
Diagnostic Lab Data: autopsy performed
CDC Split Type:

Write-up: mom noticed irritability p/vax;pt recv APAP-1hr later, pt went to sleep;later when mom check on pt pt pale, unresponsive-paramedics were called;pt transfer to hosp where pt later expire (about 3hr p/1st sx)


VAERS ID: 86931 (history)  
Form: Version 1.0  
Age: 0.1  
Sex: Male  
Location: Missouri  
Vaccinated:1996-06-03
Onset:1996-06-05
   Days after vaccination:2
Submitted: 1996-06-05
   Days after onset:0
Entered: 1996-06-13
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 433363 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2006A2 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 430171 / 1 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Apnoea, Cyanosis
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-06-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: unk
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was found blue & not breathing @ 07:45;EMS & medical examiner called to scene (pt''s home);pt father states baby had been acting fine prior to this AM-last saw baby 0130 & hadn''t noticed any problems


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