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This is VAERS ID 113383

Case Details

VAERS ID: 113383 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: California  
Vaccinated:1980-05-01
Onset:1980-05-04
   Days after vaccination:3
Submitted: 1998-08-10
   Days after onset:6672
Entered: 1998-08-12
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -
OPV: POLIO VIRUS, ORAL (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Military       Purchased by: Military
Symptoms: Unevaluable event
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 1980-05-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: pt sibling exp ITP @ 1 w/DTP/OPV/MMR dose 1;~ ()~~~In Sibling
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: On 5/1/80, pt recv vax and on 5/4/80, pt expired. Pt exp no fever, no crying, and no symptoms.


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