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This is VAERS ID 161853

Case Details

VAERS ID: 161853 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Mississippi  
Vaccinated:2000-10-03
Onset:2000-10-09
   Days after vaccination:6
Submitted: 2000-11-06
   Days after onset:28
Entered: 2000-11-15
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / SMITHKLINE BEECHAM 918A2 / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 0298K / 1 LL / IM
IPV: POLIO VIRUS, INACT. (POLIOVAX) / CONNAUGHT LTD. R0668 / 1 LL / -

Administered by: Private       Purchased by: Public
Symptoms: Cardio-respiratory arrest, Sudden infant death syndrome
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Neonatal disorders (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2000-10-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: premature birth, twin
Allergies:
Diagnostic Lab Data: Autopsy - SIDS
CDC Split Type: MS00043

Write-up: The pt was presented to the ER on 10/9/00 in cardiopulmonary arrest. This occurred 6 days post vax. A full autopsy was performed and cause of death is SIDS.


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