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This is VAERS ID 111830

Case Details

VAERS ID: 111830 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Wisconsin  
Vaccinated:1998-03-11
Onset:1998-03-12
   Days after vaccination:1
Submitted: 1998-04-24
   Days after onset:42
Entered: 1998-06-15
   Days after submission:52
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0002H / 1 - / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M12942 / 1 - / SC

Administered by: Public       Purchased by: Public
Symptoms: Gastrointestinal disorder, Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: hepatitis B 1st dose @ hosp 1JAN98
Current Illness: NONE
Preexisting Conditions: reflux GE
Allergies:
Diagnostic Lab Data: cult from autopsy were negative grade II reflux UGI x-ray done on 22JAN98 positive results;
CDC Split Type: WI98020

Write-up: died of SIDS COD per autopsy report 30MAR98;pt recv vax 11MAR98;


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