|
VAERS ID: |
178592 (history) |
Form: |
Version 1.0 |
Age: |
99.0 |
Sex: |
Male |
Location: |
Michigan |
Vaccinated: | 2001-11-20 |
Onset: | 2001-11-23 |
Days after vaccination: | 3 |
Submitted: |
2001-12-04 |
Days after onset: | 11 |
Entered: |
2001-12-05 |
Days after submission: | 1 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
UO691AA / 6 |
RA / IM |
Administered by: Other Purchased by: Private Symptoms: Nephritis,
Pyrexia,
Urinary retention,
Urine analysis abnormal,
White blood cell disorder SMQs:, Acute renal failure (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-11-23
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: UNK Preexisting Conditions: UNK Allergies: Diagnostic Lab Data: Positive for bacteria in urine, polynephritis, WBC 40,000 +. CDC Split Type:
Write-up: High fever 1 AM on 11/23/2001. Taken to hospital. Diagnosis of Urosepsis. |
|
VAERS ID: |
178960 (history) |
Form: |
Version 1.0 |
Age: |
3.0 |
Sex: |
Male |
Location: |
Missouri |
Vaccinated: | 2001-11-28 |
Onset: | 2001-11-28 |
Days after vaccination: | 0 |
Submitted: |
2001-11-28 |
Days after onset: | 0 |
Entered: |
2001-12-13 |
Days after submission: | 15 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
4018041 / 5 |
RA / IM |
Administered by: Public Purchased by: Public Symptoms: Child maltreatment syndrome SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-11-28
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: Phenobarbital; Baclofen; Robinul; Extendryl; Zyrtec Syrup; Nasonex Spray; Senocot Children''s Syrup; NaFl; Acetaminophen Solution; Atrovent Neb Current Illness: NONE Preexisting Conditions: Shaken baby syndrome at 5 weeks of age; Blind; CA; Seizures; 13 weeks premature; Disorder microcephaly; NPO with G-tubes Allergies: Diagnostic Lab Data: NONE CDC Split Type: MO2001063
Write-up: The pt had no problems immediately after injection or prior to being discovered dead in crib at 05:45 on 11/28/01. On the last check of pt at 03:00 on 11/28/01, he was laughing and playing. Death certificate indicates the child died from shaken baby syndrome (suffering from this since 5 weeks old according to the dept of health). |
|
VAERS ID: |
179130 (history) |
Form: |
Version 1.0 |
Age: |
40.0 |
Sex: |
Male |
Location: |
New York |
Vaccinated: | 2001-11-30 |
Onset: | 2001-12-01 |
Days after vaccination: | 1 |
Submitted: |
2001-12-13 |
Days after onset: | 12 |
Entered: |
2001-12-18 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / EVANS VACCINES |
E04831KA / 1 |
- / IM |
Administered by: Private Purchased by: Private Symptoms: Cardio-respiratory arrest,
Convulsion SMQs:, Torsade de pointes/QT prolongation (broad), 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), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-12-01
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Inderal; Metamucil; Ativan; Vitamin E; Cogentin; Risperdal Current Illness: NONE Preexisting Conditions: Development disability; severe MR; mild to moderate scoliosis; intermittent explosive disorder; PICA; history of pin worms; allergy to Navane and Nitrous Oxide Allergies: Diagnostic Lab Data: Autopsy performed CDC Split Type:
Write-up: No symptoms of adverse reaction noted following administration of vaccine. Autopsy performed and cause of death was listed as "Cardiorespiratory failure as a consequence of seizure". |
|
VAERS ID: |
179131 (history) |
Form: |
Version 1.0 |
Age: |
77.0 |
Sex: |
Female |
Location: |
New York |
Vaccinated: | 2001-11-16 |
Onset: | 2001-12-07 |
Days after vaccination: | 21 |
Submitted: |
2001-12-13 |
Days after onset: | 6 |
Entered: |
2001-12-18 |
Days after submission: | 5 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / EVANS VACCINES |
E04831KA / 1 |
- / IM |
Administered by: Private Purchased by: Private Symptoms: 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: 2001-12-07
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: Current Illness: NONE Preexisting Conditions: Development disability, Down''s Syndrome Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: No symptoms of adverse reaction noted following administration of vaccine. Cause of death pneumonia. |
|
VAERS ID: |
179151 (history) |
Form: |
Version 1.0 |
Age: |
57.0 |
Sex: |
Male |
Location: |
Ohio |
Vaccinated: | 2001-11-02 |
Onset: | 2001-11-29 |
Days after vaccination: | 27 |
Submitted: |
2001-12-17 |
Days after onset: | 18 |
Entered: |
2001-12-18 |
Days after submission: | 1 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U0675BA / UNK |
RA / IM |
Administered by: Public Purchased by: Private Symptoms: Guillain-Barre syndrome,
Lung disorder SMQs:, Peripheral neuropathy (narrow), Guillain-Barre syndrome (narrow), Demyelination (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? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? Yes
Previous Vaccinations: Other Medications: metformin; allopurinol Current Illness: Preexisting Conditions: NONE Allergies: Diagnostic Lab Data: NONE CDC Split Type:
Write-up: Guillain Barre syndrome, axonal form. Per doc 214332, 60 day follow-u, patient was discharged to a rehabilitation facility. He reportedly died several days later. I am unsure at the cause of death, though I suspect he may have suffered a massive pulmonary embolism. |
|
VAERS ID: |
179213 (history) |
Form: |
Version 1.0 |
Age: |
34.0 |
Sex: |
Female |
Location: |
Washington |
Vaccinated: | 2001-12-10 |
Onset: | 2001-12-11 |
Days after vaccination: | 1 |
Submitted: |
2001-12-12 |
Days after onset: | 1 |
Entered: |
2001-12-19 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
UO708AA / UNK |
- / IM |
Administered by: Private Purchased by: Private Symptoms: Overdose SMQs:, Drug abuse and dependence (broad), Medication errors (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-12-11
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: Sulfa allergy Allergies: Diagnostic Lab Data: Autopsy-pending CDC Split Type:
Write-up: Unexplained death. Awaiting autopsy COD as per autopsy report -- combination of methadone and oxycodone intoxication |
|
VAERS ID: |
179927 (history) |
Form: |
Version 1.0 |
Age: |
64.0 |
Sex: |
Male |
Location: |
South Carolina |
Vaccinated: | 2000-11-14 |
Onset: | 2000-11-14 |
Days after vaccination: | 0 |
Submitted: |
2000-12-15 |
Days after onset: | 31 |
Entered: |
2002-01-14 |
Days after submission: | 395 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. |
E66350NA / UNK |
RA / IM |
Administered by: Public Purchased by: Unknown Symptoms: Cardiac arrest,
Coma SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), 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), 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: 2000-11-14
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: Current Illness: NONE Preexisting Conditions: PCN allergy; history of diabetes and hypertension. Allergies: Diagnostic Lab Data: CDC Split Type: SC00094
Write-up: The pt received influenza vaccine during AM hours. The pt seemed fine for several hours but was found unresponsive by a neighbor that afternoon. Resuscitation efforts failed and the pt was pronounced dead at 17:52 on 11/14/00. Her death was felt to be sudden cardiac death with a history of diabetes and hypertension. Please not the date of the event, 11/14/01, is the correct date. The pt died on the same day he received influenza immunization. |
|
VAERS ID: |
180784 (history) |
Form: |
Version 1.0 |
Age: |
71.0 |
Sex: |
Male |
Location: |
New York |
Vaccinated: | 2001-12-26 |
Onset: | 2001-12-28 |
Days after vaccination: | 2 |
Submitted: |
2002-01-25 |
Days after onset: | 28 |
Entered: |
2002-02-01 |
Days after submission: | 7 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH |
4018029 / 1 |
LA / IM |
Administered by: Private Purchased by: Private Symptoms: Apnoea,
Cardiac arrest,
Chest discomfort,
Dizziness,
Eructation,
Hypercholesterolaemia,
Hyperhidrosis,
Lethargy,
Nasal congestion,
Pain SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Lipodystrophy (broad), Respiratory failure (narrow), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-12-28
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: Atenolol; Synthroid Current Illness: NONE Preexisting Conditions: Chronic controlled hypertension; hypothyroidism; allergic to PCN Allergies: Diagnostic Lab Data: Last cholesterol was 225. CDC Split Type:
Write-up: At 24 hours pt felt lethargic, dizzy. After dinner that night he was sweating, burping. At 48 hours pt had pain in left arm, congestion and tightness in chest. COD as per death certificate -- cardiorespiratory arrest |
|
VAERS ID: |
181457 (history) |
Form: |
Version 1.0 |
Age: |
68.0 |
Sex: |
Male |
Location: |
Iowa |
Vaccinated: | 2001-10-09 |
Onset: | 2001-10-10 |
Days after vaccination: | 1 |
Submitted: |
2001-10-19 |
Days after onset: | 9 |
Entered: |
2002-02-19 |
Days after submission: | 123 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U0572EA / UNK |
LA / IM |
Administered by: Public Purchased by: Private Symptoms: Bacterial infection,
Cardiogenic shock,
Chills,
Pyrexia SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2001-10-10
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: Heart valve replacement; CAD Allergies: Diagnostic Lab Data: C & S X 2-reported as staph aureus CDC Split Type: IL01053
Write-up: We were contacted by HD who received a call from a MD stating pt received flu shot on 10/09/01 and developed rigors and a fever of 103F later that night. He was seen in ER and developed cardiogenic shock and died. |
|
VAERS ID: |
182147 (history) |
Form: |
Version 1.0 |
Age: |
73.0 |
Sex: |
Male |
Location: |
Unknown |
Vaccinated: | 1998-10-20 |
Onset: | 1998-10-23 |
Days after vaccination: | 3 |
Submitted: |
0000-00-00 |
Entered: |
2002-03-11 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / MEDEVA PHARMA, LTD. |
- / UNK |
- / IM |
Administered by: Unknown Purchased by: Unknown Symptoms: Tracheobronchitis SMQs:
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: Other Medications: Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: CDC Split Type: PJP200200178
Write-up: A report received on 2/28/02, is concerning a 73 year old male pt who experienced life-threatening tracheobronchitis, for which he was hospitalized, 3 days after receiving Fluvirin vaccine, on 10/20/1998. The pt died subsequently. It is unclear from the report what the cause of death was. The causality was stated to be possibly related. No further information was provided. |
|