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This is VAERS ID 114230

Case Details

VAERS ID: 114230 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Female  
Location: Arkansas  
Vaccinated:1998-09-10
Onset:1998-09-10
   Days after vaccination:0
Submitted: 1998-09-11
   Days after onset:1
Entered: 1998-09-21
   Days after submission:10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 453846 / 2 LL / IM
HIBV: HIB (PROHIBIT) / CONNAUGHT LABORATORIES 0942550 / 2 RL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. N00321 / 2 RL / SC

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1998-09-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: NONE~ ()~~~In patient
Other Medications: Lactalose;Cardac Dm
Current Illness: nasal congestion
Preexisting Conditions: constipation
Allergies:
Diagnostic Lab Data:
CDC Split Type: AR9852

Write-up: pt was seen in the office on 10SEP98 for 4mo check up;recv vax died early evening on 10SEP98;15SEP98 MD reports poss SIDS:vaccine related pending;


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