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This is VAERS ID 111830

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 111830
VAERS Form:
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX / SMITHKLINE 826A2 / 0 - / IM
HIBV: PEDVAXHIB / MSD 0002H / 0 - / IM
IPV: POLIOVAX / CONNAUGHT LTD M12942 / 0 - / SC

Administered by: Public      Purchased by: Unknown
Symptoms: SIDS, GI DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: 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':

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


Changed on 12/8/2009

VAERS ID: 111830 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-16 1998-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: INFANRIX DTAP (INFANRIX) / SMITHKLINE SMITHKLINE BEECHAM 826A2 / 0 - / IM
HIBV: PEDVAXHIB HIB (PEDVAXHIB) / MSD MERCK & CO. INC. 0002H / 0 - / IM
IPV: POLIOVAX POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD CONNAUGHT LTD. M12942 / 0 - / SC

Administered by: Public      Purchased by: Unknown Public
Symptoms: Gastrointestinal disorder, SIDS, Sudden infant death syndrome, GI DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: 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': (blank) WI98020

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


Changed on 5/14/2017

VAERS ID: 111830 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0002H / 0 - / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M12942 / 0 - / SC

Administered by: Public      Purchased by: Public
Symptoms: Gastrointestinal disorder, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 9/14/2017

VAERS ID: 111830 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 826A2 / 0 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0002H / 0 1 - / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. M12942 / 0 1 - / SC

Administered by: Public      Purchased by: Public
Symptoms: Gastrointestinal disorder, Sudden infant death syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 2/14/2018

VAERS ID: 111830 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 6/14/2018

VAERS ID: 111830 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 8/14/2018

VAERS ID: 111830 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 9/14/2018

VAERS ID: 111830 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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;


Changed on 10/14/2018

VAERS ID: 111830 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:Wisconsin
Vaccinated:1998-03-11
Onset:1998-03-12
Submitted:1998-04-24
Entered:1998-06-15
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-03-12
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: ~ ()~~~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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