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This is VAERS ID 158090

Case Details

VAERS ID: 158090 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Connecticut  
Vaccinated:1997-09-15
Onset:0000-00-00
Submitted: 2000-07-25
Entered: 2000-07-28
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 7BF1603 / 2 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0312E / 2 RL / IM
HIBV: HIB (ACTHIB) / CONNAUGHT LABORATORIES 9D91711 / 2 RL / IM
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / PASTEUR MERIEUX INST. M1294 / 2 LL / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-10-10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data: autopsy case #97-10761
CDC Split Type:

Write-up: Pt was found in his crib at daycare on 10/10/1997, having died from SIDS. Doctor spoke with other doctor on 10/15/1997, who said that the autopsy confirmed SIDS.


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