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This is VAERS ID 28327

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 28327
VAERS Form:
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL / LEDERLE 275970 / 1 RL / IM
OPV: ORIMUNE / LEDERLE 287954 / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: AGITATION, FEVER, DEHYDRAT, EYE DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type':

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 12/8/2009

VAERS ID: 28327 Before After
VAERS Form:
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-21 1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: TRI-IMMUNOL DTP (TRI-IMMUNOL) / LEDERLE LEDERLE LABORATORIES 275970 / 1 RL / IM
OPV: ORIMUNE POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LEDERLE LABORATORIES 287954 / 1 - / PO

Administered by: Public      Purchased by: Unknown Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia, AGITATION, FEVER, DEHYDRAT, EYE DIS

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': (blank) LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 5/14/2017

VAERS ID: 28327 Before After
VAERS Form:
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 1 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 287954 / 1 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 9/14/2017

VAERS ID: 28327 Before After
VAERS Form:(blank) 1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 1 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 1 2 - MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 2/14/2018

VAERS ID: 28327 Before After
VAERS Form:1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 6/14/2018

VAERS ID: 28327 Before After
VAERS Form:1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 8/14/2018

VAERS ID: 28327 Before After
VAERS Form:1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 9/14/2018

VAERS ID: 28327 Before After
VAERS Form:1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S


Changed on 10/14/2018

VAERS ID: 28327 Before After
VAERS Form:1
Age:1.2
Sex:Male
Location:Louisiana
Vaccinated:1990-12-27
Onset:1991-01-02
Submitted:1991-01-15
Entered:1991-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTP: DTP (TRI-IMMUNOL) / LEDERLE LABORATORIES 275970 / 2 RL / IM
OPV: POLIO VIRUS, ORAL (ORIMUNE) / PFIZER/WYETH 287954 / 2 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Agitation, Dehydration, Eye disorder, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1991-01-02
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: Tylenol
Current Illness:
Preexisting Conditions: 26 wks preme, hx of hyaline membrane disease, sepsis, necrotizing enterocolitis /w small bowel resec, malabsorption, formula intolerance
Allergies:
Diagnostic Lab Data: CSF-clear, WBC-0, RBC-5, 0-Segs & Lymphs
CDC 'Split Type': LA910203

Write-up: Mom noted listlessness & dark circles around eyes in am 2Jan, pt taken Hosp arrived @ 11am, found to have T 103, T escalating, pt died @ 1130 am, cause of death - dehydration, No fever noted @ time of Immun. to arrival @ hosp, no neuro S+S

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