|
| VAERS ID: |
338667 (history) |
| Form: |
Version 1.0 |
| Age: |
1.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2009-01-27 |
| Onset: | 2009-01-28 |
| Days after vaccination: | 1 |
| Submitted: |
2009-01-28 |
| Days after onset: | 0 |
| Entered: |
2009-01-30 |
| Days after submission: | 2 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U2810AA / 2 |
RL / UN |
| HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AHAVB274AD / 1 |
RL / UN |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
1369X / 1 |
LL / UN |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
021052 / 4 |
RL / UN |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
1406X / 1 |
LL / UN |
Administered by: Private Purchased by: Private
Symptoms: Autopsy
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-01-28
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Autopsy is being performed
CDC Split Type:
Write-up: Sudden death at home morning of 1/28/09. 6/1/09 Autopsy report states COD as sudden unexpected infant death & manner of death as natural. Report also states patient found dead in crib, tox screens & cultures all neg. |
|
| VAERS ID: |
340286 (history) |
| Form: |
Version 1.0 |
| Age: |
14.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2009-01-23 |
| Onset: | 2009-02-13 |
| Days after vaccination: | 21 |
| Submitted: |
2009-02-20 |
| Days after onset: | 7 |
| Entered: |
2009-02-20 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
U2808AA / 1 |
UN / IM |
Administered by: Private Purchased by: Public
Symptoms: Chest X-ray abnormal,
Cough,
Influenza serology positive,
Pneumonia,
Pyrexia,
Staphylococcus identification test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 2009-03-21
Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 35 days
Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Staph Aureus; Infl B positive; X ray chest diffuse pneumonia LABS: Admit labs: WBC 0.9(L), plts 41K(L) CRP 26.6(H), RA factor 16(H).Drug screen neg. Head CT WNL. Bone marrow biopsy.
CDC Split Type:
Write-up: Fever, cough. Diffuse bilateral pneumonia. Staph aureus MRSA. 5/12/09 Autopsy report states COD as organizing diffuse alveolar damage w/bronchiectasis; multiple bronchopleural fistulas secondary to influenza B & MRSA infection; extensive pleural adhesions. Autopsy limited to lung only. 4/15/09 Received hospital medical records of 2/16-3/21/2009. FINAL DX: death; influenza B pneumonia w/secondary MRSA pneunonia; ARDS; leukopenia; thrombocytopenia; hyponatremia; coagulopathy; hypotension requiring pressors; high frequency oscillatory ventilation; bilateral pneumothorax; bilateral bronchopulmonary fistulas. Records reveal patient experienced sorethroat, fever, cough, post-tussive emesis x 4-5 days & hemoptysis x 1 day prior to admit w/increased work of breathing. Admitted PICU for severe respiratory distress secondary to bilat pneumonia & leukopenia. Pulm, ID, heme consults done. Patient had long & complicated PICU course while continuously vented, feeding tube, bilateral chest tubes, tracheostomy, multiple blood product transfusions, IV antibiotics & steroids, Tamiflu, IVIG. Progressively declined, extubated per family request & expired shortly therafter. |
|
| VAERS ID: |
340925 (history) |
| Form: |
Version 1.0 |
| Age: |
0.5 |
| Sex: |
Female |
| Location: |
Texas |
| Vaccinated: | 2009-01-14 |
| Onset: | 2009-02-10 |
| Days after vaccination: | 27 |
| Submitted: |
0000-00-00 |
| Entered: |
2009-03-02 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR |
C2903AA / 3 |
RL / IM |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
UT2794CA / 1 |
LL / IM |
| PNC: PNEUMO (PREVNAR) / PFIZER/WYETH |
C83143 / 3 |
LL / IM |
| RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. |
1172X / 3 |
MO / PO |
Administered by: Private Purchased by: Public
Symptoms: Death,
Influenza
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-02-10
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient died of influenza A on 2/10/09. 3/16/09-preliminary anatomic diagnoses received-Influenza A infection with Staphylococcus aureus superinfection and septic shock. Bilateral hemorrhagic bronchopneumonia. Staphylococcus aureus isolated on postmortem lung culture;antibiotic sensitivity pending. Influenza A virus identified by PCR testing on antemortem tracheal aspirate. Bilateral adrenal hemorrhage Waterhouse-Friderichsen syndrome). Coagulopathy widespread glomerular microthrombi. Congestive organomegaly, lungs, liver, kidneys and spleen. Admitted 2/10/09. |
|
| VAERS ID: |
359582 (history) |
| Form: |
Version 1.0 |
| Age: |
62.0 |
| Sex: |
Female |
| Location: |
North Carolina |
| Vaccinated: | 2009-09-23 |
| Onset: | 2009-09-25 |
| Days after vaccination: | 2 |
| Submitted: |
2009-10-06 |
| Days after onset: | 11 |
| Entered: |
2009-10-06 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / NOVARTIS VACCINES AND DIAGNOSTICS |
97848PIC / 1 |
LA / IM |
Administered by: Unknown Purchased by: Unknown
Symptoms: Death,
Dyspnoea,
Influenza like illness,
Mechanical ventilation,
Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-05
Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Psoriasis PMH: psoriasis Allergies: PCN
Allergies:
Diagnostic Lab Data: Labs and Diagnostics: H1N1 (-). Labs: Admission: CBC norm, CMP: Na 127, K-3.2, Albumin-1.9 all Low, Creatinine 2.4, BUN-36, AST-158, ALT-81 all HIgh Viral respiratory panel neg, MRSA screening negative, Urine strep pneumonia antigen negative, Mycoplasma IgM AB negative, Urine Legionella antigen negative, Blood and Urine cultures negative Dx studies/Xrays: CXR multilobar pneumonia , Echocardiogram pericardial effusion
CDC Split Type:
Write-up: Flu like symptoms: Fever, SOB. Was admitted to the hospital on 9/25/09 and was diagnosed with H1N1 and deteriorated; was placed on a ventilator and expired on 10/5/09 at approxitmately 1800 hours. 10/9/09 Prelim autopsy report received with the following findings: Multilobar pneumonia (all lobes severely involved). Post mortem bacterial, fungal, acid fast and viral cultures pending. H1N1 (-). Renal failure probably 2'' to acute tubular necrosis. 10/21/2009 hospital records for date 10/1- 10/5/ 2009, patient with 1 week hx of fever, malaise. nausea, vomiting, and chest discomfort. Saw PCP 9/26/2009 and thought to be viral, sx progressed, cough worsened and patient became dyspneic. To hospital 10/1/2009 in respiratory failure. TX: placed on continuous ventilation with nitrous oxide and pressors, IV ABX Zyvox, Clindamycin, Levaquin, Aztreonam, Cleocin, Xigris, Serum Bicarbonate. DC DX''s: Severe Multilobar Pneumonia, Respiratory failure, Renal failure, Metabolic Acidosis. 12/29/09 Autopsy report received. DOD 10/5/2009. Cause of Death: Multilobar pneumonia secondary to Legionella, non-pneumophilia species. Additional information abstracted: Patient developed community-acquired bilateral pneumonia causing severe hypoxia and multiorgan system failure. |
|
| VAERS ID: |
359602 (history) |
| Form: |
Version 1.0 |
| Age: |
75.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2009-09-24 |
| Onset: | 2009-09-27 |
| Days after vaccination: | 3 |
| Submitted: |
2009-10-16 |
| Days after onset: | 19 |
| Entered: |
2009-10-06 |
| Days after submission: | 10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLUX: INFLUENZA (SEASONAL) (NO BRAND NAME) / SANOFI PASTEUR |
U3192AA / 2 |
LA / - |
Administered by: Unknown Purchased by: Unknown
Symptoms: Abasia,
Lumbar puncture
SMQs:, Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-12
Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: kidney stone issues
Preexisting Conditions: hx polio, prostate ca, hyperlipediemia, smokes, emphesema, diverticulitis, hemmroids, ventral hernia, osteoarthritis, skin ca, no allergies. 10/19/09 Physician fax received for date of service 10/12/09.PMH: Post-Polio syndrome. 12/1/09 ED and Hospital records received. Service dates 9/28/09 to 10/12/09. PMH: Polio with kyphoscoliosis, atrophy (L) lower extremity and arm. Nephrolithiasis. Carcinoma of prostate. Hyperlipidemia. Diverticulosis / Diverticulitis. Hemorrhoids, tosillectomy, ventral hernia, basal cell carcinoma of skin, osteoarthritis.
Allergies:
Diagnostic Lab Data: LP done. 10/19/09 Physician fax received for date of service 10/12/09. Labs and Diagnostics: EMG: Denervation distally. 12/1/09 ED and Hospital records received. Service dates 9/28/09 to 10/12/09. LABS and DIAGNOSTICS: Chest X-ray - Abnormal. EMG - Abnormal. MRI Brain Abnormal. Abdominal US - Abnormal. ECG - Abnormal. CBC - WBC 11.4 (H) RBC 3.47 (L) HGB 11.1 (L) HCT 32.2 (L). CHEM - Glucose 123 (H) Calcium 8.1 (L) ALKPHOSPH 236 (H) AST 171 (H) ALT 287 (H).
CDC Split Type:
Write-up: he had a hard time navigating to the bathroom on 2 separate occasions and is unable to walk on his own. 10/19/09 Physician fax received for date of service 10/12/09. Dx: Death secondary to Guillain-Barre Syndrome. Assessment: Intubated due to GBS. EMG showed denervation distally. Due to increased neuronal injury and poor prognosis (also coupled with post-Polio syndrome) the family decided to extubate the patient. 12/1/09 ED and Hospital records received. Service dates 9/28/09 to 10/12/09. Assessment: Severe Guillian-Barre Syndrome. Patient developed profound, progressive and generalized weakness over the last 24-36 hours. Numbness toes, feet, fingers. Unable to walk on his own. Peripheral edema. Rhonchi bilateral. Intubated. Subdural hematoma. Hematuria with clots. Gallbladder polyp, Renal cyst. Atrial fibrillation. Sinus Bradycardia. Left ventricular hypertrophy. Nonresponsive to voice / touch. DTR''s absent. IVIG Administered. |
|
| VAERS ID: |
359951 (history) |
| Form: |
Version 1.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2009-10-02 |
| Onset: | 2009-10-03 |
| Days after vaccination: | 1 |
| Submitted: |
2009-10-07 |
| Days after onset: | 4 |
| Entered: |
2009-10-07 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / NOVARTIS VACCINES AND DIAGNOSTICS |
97844P2 / UNK |
LA / IM |
Administered by: Private Purchased by: Other
Symptoms: Encephalitis,
Mental status changes
SMQs:, Dementia (broad), Noninfectious encephalitis (narrow), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-11-24
Days after onset: 52
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 51 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: See report
CDC Split Type:
Write-up: 10/3 - started with mental changes 24 hours after influenza vaccine. Dx with encephalitis. |
|
| VAERS ID: |
360397 (history) |
| Form: |
Version 1.0 |
| Age: |
86.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2009-10-02 |
| Onset: | 2009-10-02 |
| Days after vaccination: | 0 |
| Submitted: |
2009-10-02 |
| Days after onset: | 0 |
| Entered: |
2009-10-12 |
| Days after submission: | 10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / NOVARTIS VACCINES AND DIAGNOSTICS |
98441P1A / UNK |
RA / UN |
Administered by: Private Purchased by: Other
Symptoms: Cardiac arrest,
Circulatory collapse,
Death,
Malaise
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-02
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Kidney stones.
Allergies:
Diagnostic Lab Data: None performed
CDC Split Type:
Write-up: Patient to PMD for physical. Was feeling well and received flu vaccine. Upon arriving home minutes later told wife "I don''t feel well" and collapsed. Brought to ED in full cardiac arrest. Unable to resuscitate. 10/19/09 ER records received service date 10/2/09. Assessment: Cardiac Arrest. Patient arrived unresponsive, intubated with CPR in progress. Asystole on monitor with no spontaneous respirations. External trauma to eyes. ICD-9 code 427.5 cardiac arrest. 12/16/09 Death Certificate received. DOD 10/02/09. Cause of Death - Hypertensive and arteriosclerotic heart disease. |
|
| VAERS ID: |
360527 (history) |
| Form: |
Version 1.0 |
| Age: |
47.0 |
| Sex: |
Female |
| Location: |
Kentucky |
| Vaccinated: | 2009-09-22 |
| Onset: | 0000-00-00 |
| Submitted: |
2009-10-09 |
| Entered: |
2009-10-12 |
| Days after submission: | 3 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
C3202AA / 2 |
LA / IM |
| TDAP: TDAP (ADACEL) / SANOFI PASTEUR |
C3249AA / 2 |
LA / IM |
Administered by: Public Purchased by: Public
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-03
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: None stated. 11/30/09 Death Certificate Received. DOD 10/03/2009. Final Cause of Death: Acute Methadone Toxicity. Additional Information - Underlying conditions: Constrictive Atherosclerotic Artery Disease. |
|
| VAERS ID: |
360706 (history) |
| Form: |
Version 1.0 |
| Age: |
76.0 |
| Sex: |
Female |
| Location: |
Virginia |
| Vaccinated: | 2009-10-02 |
| Onset: | 2009-10-03 |
| Days after vaccination: | 1 |
| Submitted: |
2009-10-13 |
| Days after onset: | 10 |
| Entered: |
2009-10-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUVIRIN) / NOVARTIS VACCINES AND DIAGNOSTICS |
98431P1 / UNK |
LA / UN |
Administered by: Other Purchased by: Private
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-03
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin; Aricept; Coreg; HCTZ; Lexapro; Lisinopril; Synthroid; Namend; Insulin; Simvastatin
Current Illness: Diabetes; HTN; Dementia; hypothyroidism
Preexisting Conditions: NKDA
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt. expired on 10/3/09. Attending MD did not believe immunization was cause of death but reported because of dose temporal proximity. (Pt. expired approx. 24 hrs after receiving the flu vaccine). 10/16/09 Death Certificate: Cardiorespiratory arrest, Diabetes mellitus type 2, Hypertension. |
|
| VAERS ID: |
360751 (history) |
| Form: |
Version 1.0 |
| Age: |
1.04 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2009-10-01 |
| Onset: | 2009-10-04 |
| Days after vaccination: | 3 |
| Submitted: |
2009-10-08 |
| Days after onset: | 4 |
| Entered: |
2009-10-14 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR |
UT3178DA / 1 |
RL / UN |
| HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS |
AHAVB334BA / 1 |
LL / UN |
| HIBV: HIB (ACTHIB) / SANOFI PASTEUR |
UF673AA / 4 |
RL / UN |
| MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. |
0554Y / 1 |
LL / UN |
| VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. |
0731Y / 1 |
RA / UN |
Administered by: Private Purchased by: Unknown
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2009-10-04
Days after onset: 0
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: Seizure disorder; DANDY WALKER syndrome
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was seen on 10/1/09. Death reported on 10/4/09. Pt has seizure disorder along with encephalocele. / DANDY WALKER Syndrome. Had received vaccines on 10/1/09. |
|
