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This is VAERS ID 105194

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 105194
VAERS Form:
Age:3.8
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-12-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUSHIELD 1997-1998 / WYETH 4978218 / 0 - / IM

Administered by: Private      Purchased by: Unknown
Symptoms: SOMNOLENCE

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 12/8/2009

VAERS ID: 105194 Before After
VAERS Form:
Age:3.8 3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-12-01 1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: FLUSHIELD 1997-1998 INFLUENZA (SEASONAL) (FLUSHIELD 97-98) / WYETH WYETH PHARMACEUTICALS, INC 4978218 / 0 - / IM

Administered by: Private (blank)      Purchased by: Unknown (blank)
Symptoms: Somnolence, SOMNOLENCE

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 8/31/2010

VAERS ID: 105194 Before After
VAERS Form:
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUSHIELD 97-98) INFLUENZA (SEASONAL) (FLUSHIELD) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 4978218 / 0 - / IM

Administered by: ??      Purchased by: ??
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 7/7/2013

VAERS ID: 105194 Before After
VAERS Form:
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 0 - / IM
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 0 - / IM

Administered by: ??      Purchased by: ??
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 5/14/2017

VAERS ID: 105194 Before After
VAERS Form:
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 0 - / IM

Administered by: (blank) Private      Purchased by: (blank) Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 9/14/2017

VAERS ID: 105194 Before After
VAERS Form:(blank) 1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 0 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 2/14/2018

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 6/14/2018

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 8/14/2018

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 9/14/2018

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 10/14/2018

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 12/24/2020

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

Changed on 12/30/2020

VAERS ID: 105194 Before After
VAERS Form:1
Age:3.0
Sex:Male
Location:New York
Vaccinated:1997-11-06
Onset:1997-11-09
Submitted:1997-11-21
Entered:1997-11-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUSHIELD) / PFIZER/WYETH 4978218 / 1 - / IM

Administered by: Private      Purchased by: Other
Symptoms: Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-11-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: hydroencephaly, shunted hydrocephalis, cerebral palsy
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severely delayed child became lethargic;48hr p/vax brought to ED, expired during CT scan to evaluate shunt status;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=105194&WAYBACKHISTORY=ON


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