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This is VAERS ID 108656

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 108656
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA / CONNAUGHT LABS 0907380 / 1 L / IM
HEP: ENGERIX-B / SMITHKLINE 2500A2 / 1 L / IM
HIBV: PROHIBIT / CONNAUGHT LABS 0915240 / 1 L / IM
IPV: IPV / MERIEUX INST M0939 / 1 L / IM

Administered by: Private      Purchased by: Unknown
Symptoms: HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': prematurity-hx ROS/anemia

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 12/8/2009

VAERS ID: 108656 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-19 1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA DTAP (TRIPEDIA) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0907380 / 1 L / IM
HEP: ENGERIX-B HEP B (ENGERIX-B) / SMITHKLINE SMITHKLINE BEECHAM 2500A2 / 1 L / IM
HIBV: PROHIBIT HIB (PROHIBIT) / CONNAUGHT LABS CONNAUGHT LABORATORIES 0915240 / 1 L / IM
IPV: IPV POLIO VIRUS, INACT. (NO BRAND NAME) / MERIEUX INST PASTEUR MERIEUX INST. M0939 / 1 L / IM

Administered by: Private      Purchased by: Unknown Private
Symptoms: Cardiac arrest, HEART ARREST

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type': prematurity-hx ROS/anemia (blank)

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 5/14/2017

VAERS ID: 108656 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 1 L - / IM IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 1 L - / IM IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 1 L - / IM IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 1 L - / IM IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 9/14/2017

VAERS ID: 108656 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 1 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 1 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 1 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 1 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 2/14/2018

VAERS ID: 108656 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 6/14/2018

VAERS ID: 108656 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 8/14/2018

VAERS ID: 108656 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 9/14/2018

VAERS ID: 108656 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;


Changed on 10/14/2018

VAERS ID: 108656 Before After
VAERS Form:1
Age:0.3
Sex:Male
Location:New York
Vaccinated:1998-02-27
Onset:1998-03-05
Submitted:1998-03-10
Entered:1998-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 0907380 / 2 - / IM L
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2500A2 / 2 - / IM L
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0915240 / 2 - / IM L
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M0939 / 2 - / IM L

Administered by: Private      Purchased by: Private
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-05
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: NONE~ ()~~~In patient
Other Medications: Respigam
Current Illness: NONE
Preexisting Conditions: prematurity-hx ROS/anemia
Allergies:
Diagnostic Lab Data: NONE
CDC 'Split Type':

Write-up: pt expired on 5MAR98 presented to ER in full C-R arrest;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=108656&WAYBACKHISTORY=ON


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