|
VAERS ID: |
164027 (history) |
Form: |
Version 1.0 |
Age: |
|
Sex: |
Unknown |
Location: |
New Hampshire |
Vaccinated: | 0000-00-00 |
Onset: | 0000-00-00 |
Submitted: |
2000-12-18 |
Entered: |
2000-12-21 |
Days after submission: | 3 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
- / UNK |
- / IM |
Administered by: Other Purchased by: Other Symptoms: Influenza like illness 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: Other Medications: UNK Current Illness: UNK Preexisting Conditions: UNK Allergies: Diagnostic Lab Data: UNK CDC Split Type: HQ4854614DEC2000
Write-up: Post vax, the pt died. No further information was available at the date of this report. The reporter indicated that 9 pts experienced this event, however, they are not presently identifiable. 15 day follow-up states that the pt experienced flu-like symptoms as did a total of 9 pts. |
|
VAERS ID: |
164043 (history) |
Form: |
Version 1.0 |
Age: |
|
Sex: |
Unknown |
Location: |
Indiana |
Vaccinated: | 0000-00-00 |
Onset: | 0000-00-00 |
Submitted: |
2000-12-19 |
Entered: |
2000-12-21 |
Days after submission: | 2 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
- / UNK |
- / IM |
Administered by: Other Purchased by: Other Symptoms: Guillain-Barre syndrome SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), 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? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: UNK Current Illness: UNK Preexisting Conditions: UNK Allergies: Diagnostic Lab Data: UNK CDC Split Type: HQ4993318DEC2000
Write-up: Post vax, the pt developed Guillain-Barre syndrome. No further information was available at the date of this report. FU received indicated the patient was an elderly female who received 1999-2000 formula influenza virus vaccine. See related case HQ5472103JAN2001. |
|
VAERS ID: |
164060 (history) |
Form: |
Version 1.0 |
Age: |
80.0 |
Sex: |
Male |
Location: |
Pennsylvania |
Vaccinated: | 2000-11-01 |
Onset: | 2000-11-02 |
Days after vaccination: | 1 |
Submitted: |
2000-12-19 |
Days after onset: | 47 |
Entered: |
2000-12-22 |
Days after submission: | 3 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. |
E65620HA / UNK |
- / IM |
Administered by: Other Purchased by: Other Symptoms: Drug ineffective,
Myocardial infarction,
Pneumonia,
Pyrexia,
Respiratory failure SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (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), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-11-12
Days after onset: 10
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: Other Medications: Coumadin Current Illness: Preexisting Conditions: Arteriosclerotic cardiovascular disease; unknown atrial fibrillation Allergies: Diagnostic Lab Data: Influenza titer-neg CDC Split Type: MPI2000049800
Write-up: Report received on 12/12/00, via telephone from a nurse regarding a possible adverse event associated with Fluvirin. On 11/1/00, an 80 year old male pt (DOB 8/1920), received vaccination with Fluvirin and 1 day later, developed a fever of unknown origin. The pt was seen in the ER and hospitalized. He was dx''d with pneumonia and died on 11/12/00 from respiratory failure secondary to the pneumonia. An influenza titer was done during the pt''s hospitalization with negative results. On follow-up, the reporter also stated that the physician felt that it was a coincidence of events that ensued following vaccination. No other information was available at the present time. Attempts are being made to obtain further information. FU shows the pt had a non Q wave myocardial infarction. |
|
VAERS ID: |
164158 (history) |
Form: |
Version 1.0 |
Age: |
72.0 |
Sex: |
Male |
Location: |
Arizona |
Vaccinated: | 2000-12-13 |
Onset: | 2000-12-15 |
Days after vaccination: | 2 |
Submitted: |
2000-12-19 |
Days after onset: | 4 |
Entered: |
2000-12-28 |
Days after submission: | 9 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR |
U0453AA / 1 |
LA / IM |
Administered by: Private Purchased by: Private Symptoms: Myocardial infarction SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-12-15
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: K-Dur, bumetanide, nitroglycerine, Zeroxin, Lipitor, Azmacort, Atrovent Current Illness: NONE Preexisting Conditions: CAD; Chronic CHF Allergies: Diagnostic Lab Data: NONE CDC Split Type:
Write-up: Death within 48 hours, post vax; Myocardial Infarction. |
|
VAERS ID: |
164159 (history) |
Form: |
Version 1.0 |
Age: |
81.0 |
Sex: |
Female |
Location: |
Georgia |
Vaccinated: | 2000-11-30 |
Onset: | 0000-00-00 |
Submitted: |
2000-12-20 |
Entered: |
2000-12-28 |
Days after submission: | 8 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR |
U0435AA / UNK |
LA / IM |
Administered by: Other Purchased by: Public Symptoms: Unevaluable event SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-12-07
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: UNK Preexisting Conditions: CAD Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: None reported. |
|
VAERS ID: |
164361 (history) |
Form: |
Version 1.0 |
Age: |
22.0 |
Sex: |
Male |
Location: |
California |
Vaccinated: | 2000-12-05 |
Onset: | 2000-12-08 |
Days after vaccination: | 3 |
Submitted: |
2000-12-28 |
Days after onset: | 20 |
Entered: |
2001-01-03 |
Days after submission: | 6 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR |
U0428AA / UNK |
- / IM |
Administered by: Unknown Purchased by: Unknown Symptoms: Abdominal pain,
Cough,
Diarrhoea,
Headache,
Influenza like illness,
Myalgia,
Nausea,
Pharyngolaryngeal pain,
Pyrexia,
Vomiting SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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: Other Medications: Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: Autopsy-pending CDC Split Type: U200000993
Write-up: It was reported that a male pt received Fluzone SV ''00-''01 vaccination on 12/5/00. Approx. 3 days, post vax, pt developed "flu-like" symptoms. Pt was admitted to the hospital on 12/10/00. Pt expired on 12/18/00 and an autopsy was done, results not provided. Further information requested. Autopsy also states patient had headaches, muscle aches, diarrha, nausea, vomiting, fever, cough, sore throat, abdominal pain. |
|
VAERS ID: |
164478 (history) |
Form: |
Version 1.0 |
Age: |
|
Sex: |
Female |
Location: |
Indiana |
Vaccinated: | 0000-00-00 |
Onset: | 0000-00-00 |
Submitted: |
2001-01-03 |
Entered: |
2001-01-08 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
- / UNK |
- / IM |
Administered by: Other Purchased by: Other Symptoms: Guillain-Barre syndrome SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), 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? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: UNK Current Illness: UNK Preexisting Conditions: UNK Allergies: Diagnostic Lab Data: UNK CDC Split Type: HQ5472103JAN2001
Write-up: A nurse reported that a pt received an injection of 2000-2001 formula influenza virus vaccine in 2000 and subsequently, developed Guillain-Barre syndrome. This report of a serious, labeled event is being submitted in a 15-day time frame, as requested by FDA. See cancelled report, HQ4993318DEC2000. Follow-up received on 1/2/01, indicated that the pt was an elderly female who received 1999-2000 formula influenza virus vaccine. Five to 6 months, post vax, she developed Guillain-Barre syndrome. She died. |
|
VAERS ID: |
164758 (history) |
Form: |
Version 1.0 |
Age: |
66.0 |
Sex: |
Male |
Location: |
Louisiana |
Vaccinated: | 2000-12-19 |
Onset: | 2000-12-20 |
Days after vaccination: | 1 |
Submitted: |
2000-12-21 |
Days after onset: | 1 |
Entered: |
2001-01-17 |
Days after submission: | 27 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
4008175 / 1 |
- / IM |
Administered by: Public 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: 2000-12-20
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: History of heart problems in the past. Allergies: Diagnostic Lab Data: UNK CDC Split Type: LA010101
Write-up: The pt experienced a heart attach and died. The pt had a hx of heart problems in the past. |
|
VAERS ID: |
165308 (history) |
Form: |
Version 1.0 |
Age: |
75.0 |
Sex: |
Female |
Location: |
Florida |
Vaccinated: | 2000-12-13 |
Onset: | 0000-00-00 |
Submitted: |
2001-01-25 |
Entered: |
2001-01-30 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR |
U0448AA / UNK |
- / IM |
Administered by: Private Purchased by: Private Symptoms: Guillain-Barre syndrome,
Respiratory failure SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (narrow), Demyelination (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-03-28
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: Other Medications: Tiazac, Vioxx, Cozaar, Lipitor Current Illness: unspecified shortness of breath Preexisting Conditions: allergy to Motrin, HPTN, OA, gastritis, diverticulosis Allergies: Diagnostic Lab Data: CDC Split Type: U2001002100
Write-up: Sometime following vaccination, the pt developed [[name]] Barre Syndrome. The pt was hospitalized on 1/22/01. Further information is requested. F/U correspondence rec''d on 2/27/01 additional pt and the vaccine administrator info were provided. From faxed f/u correspondence rec''d on 6/18/01 for the doctor,stated that the pt was transferred from one hospital to another hospital on 2/8/01. Teh following info was sent to the doctor on 6/26/01. Date of admission to hospital 2/9/01, date of expiration 3/28/01 at 12:28pm. Dx at time of death Guillian-Barre'' syndrome immediate cause of death due to respiratory failure due to problems associated with [[name]] -Barre'' syndrome. Follow up 07/26/2001: "final diagnosis was GBS. Diagnosis was not made by a neurologist. it is not known if the patient experienced any other illnesses previous to GBS." |
|
VAERS ID: |
165497 (history) |
Form: |
Version 1.0 |
Age: |
23.0 |
Sex: |
Female |
Location: |
Texas |
Vaccinated: | 2000-11-21 |
Onset: | 2000-11-26 |
Days after vaccination: | 5 |
Submitted: |
2001-01-23 |
Days after onset: | 58 |
Entered: |
2001-02-01 |
Days after submission: | 9 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / AVENTIS PASTEUR |
40428AA / UNK |
LA / IM |
Administered by: Private Purchased by: Private Symptoms: Cerebral haemorrhage,
Cerebrovascular disorder,
Delirium,
Headache,
Vein disorder SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2000-11-26
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Celexa Current Illness: depression, stress reaction Preexisting Conditions: seasonal allergies, stress reaction, depression Allergies: Diagnostic Lab Data: NONE CDC Split Type:
Write-up: The mother states patient had a headache and had been vomiting and collapsed.Mom found her unrepsonsive. Went to ER found blood in head. Went by care flight and 2nd hospital for surgery attempted; didn''t wake, worse bleeding from "abnormal plexus of veins" in cerebellum patient expired. Death certificate states cause of death to be cerebral herniation due to rupture of cerebellar arteriovenous malformation. |
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