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This is VAERS ID 114917

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 114917
VAERS Form:
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE / LEDERLE 445540 / - LL / -
HEP: RECOMBIVAX HB / MSD 0359E / 1 RL / -
HIBV: HIBTITER / LEDERLE(PRAXIS) M195RC / - RL / -
OPV: ORIMUNE / LEDERLE 0769B / - - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: EDEMA, RESPIRAT DIS, LUNG DIS, PETECHIA, HEM

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 12/8/2009

VAERS ID: 114917 Before After
VAERS Form:
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-15 1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: ACEL-IMUNE DTAP (ACEL-IMUNE) / LEDERLE LEDERLE LABORATORIES 445540 / - LL / -
HEP: RECOMBIVAX HB HEP B (RECOMBIVAX HB) / MSD MERCK & CO. INC. 0359E / 1 RL / -
HIBV: HIBTITER HIB (HIBTITER) / LEDERLE(PRAXIS) LEDERLE PRAXSIS M195RC / - RL / -
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 0769B / - - / PO

Administered by: Private      Purchased by: Unknown Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage, EDEMA, RESPIRAT DIS, LUNG DIS, PETECHIA, HEM

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 5/14/2017

VAERS ID: 114917 Before After
VAERS Form:
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 445540 / - LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 1 RL / -
HIBV: HIB (HIBTITER) / LEDERLE PRAXSIS PFIZER/WYETH M195RC / - RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 0769B / - - / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 9/14/2017

VAERS ID: 114917 Before After
VAERS Form:(blank) 1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / - UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 1 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / - UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / - UNK - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 2/14/2018

VAERS ID: 114917 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 6/14/2018

VAERS ID: 114917 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 8/14/2018

VAERS ID: 114917 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 9/14/2018

VAERS ID: 114917 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;


Changed on 10/14/2018

VAERS ID: 114917 Before After
VAERS Form:1
Age:0.1
Sex:Female
Location:Washington
Vaccinated:1997-09-15
Onset:1997-09-21
Submitted:1998-10-05
Entered:1998-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (ACEL-IMUNE) / PFIZER/WYETH 445540 / UNK LL / -
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0359E / 2 RL / -
HIBV: HIB (HIBTITER) / PFIZER/WYETH M195RC / UNK RL / -
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 0769B / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Lung disorder, Oedema, Petechiae, Respiratory disorder, Sudden infant death syndrome, Haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1997-09-21
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: Zantac susp
Current Illness: gastroesophageal reflux
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt recv vax 16SEP97 - SIDS on 21SEP97;parents requested VAERS on 22SEP98-1yr anniversary of pt death;

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=114917&WAYBACKHISTORY=ON


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