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This is VAERS ID 490219

History of Changes from the VAERS Wayback Machine

First Appeared on 5/13/2013

VAERS ID: 490219
VAERS Form:
Age:0.2
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / - LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / - LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / - LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / - - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 9/17/2013

VAERS ID: 490219 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / - LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / - LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / - LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / - - / PO

Administered by: Private      Purchased by: Public
Symptoms: Blood culture positive, CSF culture negative, Death, Pulmonary oedema, Brain oedema, Drug screen negative, Obstructive airways disorder, Accidental death, Influenza virus test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None The following information was obtained through follow-up and/or provided by the government. Co-sleeping.
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None The following information was obtained through follow-up and/or provided by the government. 7/15/2013 lab/diagnostic records received for DOS 4/22/2013. Flu, inborn errors of metabolism, CSF cx, drug screen (-). Blood cx (+) for gram-negative bacillus, coagulase-negative staph, strep viridans.
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13. The following information was obtained through follow-up and/or provided by the government. 7/15/2013 autopsy report received for DOS 4/22/2013. COD: overlaying. Pathologic diagnoses: 1) pulmonary edema; 2) cerebral edema. Accidental occlusion of airway while co-sleeping.


Changed on 3/14/2015

VAERS ID: 490219 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / - LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / - LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / - LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / - - / PO

Administered by: Private      Purchased by: Public
Symptoms: Blood culture positive, CSF culture negative, Death, Pulmonary oedema, Brain oedema, Drug screen negative, Obstructive airways disorder, Accidental death, Influenza virus test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None The following information was obtained through follow-up and/or provided by the government. Co-sleeping.
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None The following information was obtained through follow-up and/or provided by the government. 7/15/2013 lab/diagnostic records received for DOS 4/22/2013. Flu, inborn errors of metabolism, CSF cx, drug screen (-). Blood cx (+) for gram-negative bacillus, coagulase-negative staph, strep viridans.
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13. The following information was obtained through follow-up and/or provided by the government. 7/15/2013 autopsy report received for DOS 4/22/2013. COD: overlaying. Pathologic diagnoses: 1) pulmonary edema; 2) cerebral edema. Accidental occlusion of airway while co-sleeping.


Changed on 2/14/2017

VAERS ID: 490219 Before After
VAERS Form:
Age:0.2 0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / - LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / - LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / - LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / - RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / - - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 9/14/2017

VAERS ID: 490219 Before After
VAERS Form:(blank) 1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / - UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / - UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / - UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / - UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / - UNK - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 2/14/2018

VAERS ID: 490219 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 6/14/2018

VAERS ID: 490219 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 8/14/2018

VAERS ID: 490219 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 9/14/2018

VAERS ID: 490219 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


Changed on 10/14/2018

VAERS ID: 490219 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Virginia
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted:2013-04-23
Entered:2013-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-04-21
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:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.

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