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This is VAERS ID 111504

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 111504
VAERS Form:
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 451497 / 0 LL / IM
HEP: ENGERIX-B / SMITHKLINE 2420A2 / 1 LL / IM
HIBV: HIBTITER / LEDERLE(PRAXIS) 44779D / 0 LL / IM
IPV: POLIOVAX / CONNAUGHT LTD M1351 / 0 RL / SC

Administered by: Private      Purchased by: Unknown
Symptoms: HEART ARREST, LUNG DIS, ATELECTASIS, PNEUMOTHORAX

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 12/8/2009

VAERS ID: 111504 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-09 1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 451497 / 0 LL / IM
HEP: ENGERIX-B HEP B (ENGERIX-B) / SMITHKLINE SMITHKLINE BEECHAM 2420A2 / 1 LL / IM
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE LABORATORIES 44779D / 0 LL / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. M1351 / 0 RL / SC

Administered by: Private Unknown      Purchased by: Unknown
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax, HEART ARREST, LUNG DIS, ATELECTASIS, PNEUMOTHORAX

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NONE (blank)

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 5/14/2017

VAERS ID: 111504 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 451497 / 0 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 1 LL / IM
HIBV: HIB (HIBTITER) / LEDERLE LABORATORIES PFIZER/WYETH 44779D / 0 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 0 RL / SC

Administered by: Unknown Private      Purchased by: Unknown Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 9/14/2017

VAERS ID: 111504 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 0 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 1 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 0 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 0 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 2/14/2018

VAERS ID: 111504 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 6/14/2018

VAERS ID: 111504 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 8/14/2018

VAERS ID: 111504 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 9/14/2018

VAERS ID: 111504 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;


Changed on 10/14/2018

VAERS ID: 111504 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:Michigan
Vaccinated:1998-05-18
Onset:1998-05-19
Submitted:1998-06-02
Entered:1998-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 451497 / 1 LL / IM
HEP: HEP B (ENGERIX-B) / SMITHKLINE BEECHAM 2420A2 / 2 LL / IM
HIBV: HIB (HIBTITER) / PFIZER/WYETH 44779D / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M1351 / 1 RL / SC

Administered by: Private      Purchased by: Private
Symptoms: Atelectasis, Cardiac arrest, Lung disorder, Pneumothorax

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-05-19
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: NONE
Current Illness: mild URI
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt presented to ER in full arrest p/a nap 19MAY98 1 day p/vax;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=111504&WAYBACKHISTORY=ON


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