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This is VAERS ID 159916

Case Details

VAERS ID: 159916 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Female  
Location: Texas  
Vaccinated:2000-09-11
Onset:2000-09-14
   Days after vaccination:3
Submitted: 2000-09-14
   Days after onset:0
Entered: 2000-09-20
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES U0317BB / 1 RL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 0555K / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. T0120 / 1 RL / SC
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 471655 / 1 LL / IM

Administered by: Private       Purchased by: Private
Symptoms: Cardiac arrest, Cyanosis, Respiratory arrest
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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2000-09-14
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 9/14/00, the baby was found blue and not breathing at 12:30 PM. Baby had been put to sleep at 10:30 am. Paramedics were unable to intubate due to rigor mortis. Taken to the ER and pronounced dead on arrival as pt was in asystole.


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