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This is VAERS ID 109026

Case Details

VAERS ID: 109026 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: New Hampshire  
Vaccinated:1996-02-29
Onset:0000-00-00
Submitted: 1998-03-24
Entered: 1998-04-01
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTPHIB: DTP + HIB (TETRAMUNE) / PFIZER/WYETH 427821 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 725C5 / 2 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Delirium, Encephalopathy, Hypoxia, Sudden infant death syndrome, Unevaluable event
SMQs:, Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Neonatal disorders (narrow), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1996-04-12
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: NH9636

Write-up: SIDS


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